[Latent congenital mitral insufficiency caused by an isolated mitral cleft. Diagnosis by two-dimensional echocardiography and pulsed Doppler]. / Insuffisance mitrale congénitale silencieuse due à une fente mitrale isolée. Diagnostic par échocardiographie bidimensionnelle et Doppler pulsé.

In this paper, the authors report the case of an 8-year-old boy with an isolated slit in his mitral valve, and who did not have a heart murmur detectable either by auscultation or by phonocardiography and who had no symptoms of heart failure. Two-dimensional echocardiography, with a left parasternal direction, in a transversal view revealed the presence of this abnormality of the endocardial leaflets accompanied by an accessory chorda tendina, and this procedure confirmed the absence of hemodynamic percussion. Doppler ultrasonography detected an abnormal turbulent systolic blood flow immediately behind the mitral valve, suggesting a minimal to moderate degree latent regurgitation. Two-dimensional echocardiography together with the Doppler ultrasound makes possible the diagnosis of an isolated slit of the mitral valve by non-invasive technique and the detection of concomitant latent mitral valve regurgitation, especially when the left atrium is not dilated and if the patient does not have low cardiac output.

[Effect of ventricular and sequential cardiac stimulation on carotid output]. / Effet de la stimulation cardiaque ventriculaire et séquentielle sur le débit carotidien.

12 patients (10 men and 2 women), of 59 +/- 10.5 years of age, including 4 with a patent cardiomyopathy and 7 with a cardiothoracic index higher than 0.52, presenting a permanent and complete atrio-ventricular block and fitted with a two-chambers cardiac stimulator, underwent a carotid output study by Doppler-sonography. The objective of this study was to determine the factors which could influence the carotid output: synchronous atrial systole, frequency of the electro-stimulated rhythm, atrio-ventricular delay in sequential mode, cardiomyopathy, increase of the cardiothoracic index, age and body area. It appears that the carotid output, for an identical stimulation frequency, is significantly higher in sequential mode than in one-chamber ventricular electrostimulation (p less than 0.05 at 70 c/min, p less than 0.01 at 80 c/min and p less than 0.001 at 90 c/min) and this is even more marked in case of cardiomyopathy (p less than 0.01 versus p less than 0.05). On the contrary, an elevated cardiothoracic index does not alter the nature of the results. An accelerated electrostimulated rhythm discloses an increase of the carotid output (p = 0.01) up to a threshold frequency of 70 c/min in the entire population and of 60 c/min in case of cardiomyopathy. Beyond that, the carotid output decreases. Sequential stimulation does not prevent this decrease from 80 c/min (p = 0.001). The carotid output is significantly lower (p less than 0.01) with an atrio-ventricular delay of 115 ms than with a delay of 165 ms. The carotid output decreases in direct ratio to age (p = 0.01) but the gradient of the regression axis is lower in sequential mode.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiography and connective tissue diseases]. / Echocardiographie et maladies du tissu conjonctif.

The aim of this study is to show the clinical value of the echocardiography in the heritable disorders of connective tissue, within a series of 10 cases, from 7,500 echocardiograms reviewed between 1978 and 1985. Echocardiography visualized an aneurysm of the ascending aorta in three patients, a dilatation of the pulmonary artery in one case, a mitral valve prolapse in six patients associated with an aortic and tricuspid valve prolapse in two cases, and a tricuspid valve prolapse and aortic regurgitation in one case. In two patients, an aortic valve prolapse was isolated. Other echocardiographic features were intracardiac calcifications (4 cases), septal hypertrophy (2 cases) and an incompetent foramen ovale (2 cases). Echocardiographic examination must be performed in all connective tissue diseases because cardiovascular complications are responsible for the vast majority of deaths. Conversely, all the patients with valvular prolapse, dilatation of the great vessels, aneurysm of the sinuses of Valsalva or congenital heart defects type incompetent foramen ovale should be suspected of connective tissue disorders. Such diagnosis is crucial when a surgical intervention is being considered because of the fragility of the tissues.

[Marfan's or Marfan-like syndrome: value of echocardiography]. / Syndromes de Marfan ou marfanoïdes: intérêt de l'échocardiographie.

The purpose of this study of 6 cases of Marfan's or Marfan-like syndrome detected in 7077 echocardiographic examinations was to investigate the clinical value of echocardiography. The mean age of the patients was 40 years, and 4 of them (66 p. 100) were female. The diagnosis was based on the 4 criteria of Marfan's syndrome in 1 case, on 3 criteria in 2 cases and on 2 criteria in 3 cases. Four patients were known to have a previous cardiac murmur. Auscultation revealed a systolic murmur of mitral regurgitation in 3 cases (associated with a diastolic murmur of aortic regurgitation in 2 of them), a diastolic murmur of aortic regurgitation in 3 cases and a systolic murmur due to calcified bicuspid aortic valve in 1 case. ECG recorded a normal rhythm in 4 cases, atrial fibrillation in 2 cases of mitral regurgitation, and left ventricular hypertrophy in 3 cases. Chest X-ray showed cardiomegaly in 3 patients and severe kyphoscoliosis in one. Echocardiography visualized dilatation of the ascending aorta, severe (60 mm) in 1 case, in 3 patients; dilatation of the pulmonary artery in 1 patient; pansystolic mitral valve prolapse in 3 patients (associated with aortic and tricuspid valve prolapse in 2 of them after the disease had progressed); isolated aortic valve prolapse due to bicuspid valve in 2 patients; intracardiac calcifications in 3 patients; subaortic septal hypertrophy in 1 patient and calcified incompetent foramen ovale in 1 patient. Aortography performed in 3 patients disclosed an aneurysm of Valsalva's sinuses in 1 case and a mild aortic insufficiency in 2 cases. Two patients underwent cardiac catheterization for severe mitral regurgitation due to mitral valve prolapse requiring valve replacement, which was successfully done. Thus, echocardiography may provide an early diagnosis of Marfan's syndrome, since cardiovascular abnormalities are frequent in infancy. It also ensures a close follow-up of the disorders and it is useful in deciding whether treatment should be medical or surgical. It may detect formes frustes in a family with Marfan's syndrome, and it may define a borderline group of patients: those with Marfan-like syndrome. In these patients the cardiovascular lesions are more preponderant and appear later than in the classical Marfan's syndrome; they are often difficult to differentiate from the lesions of Barlow's syndrome.

[Aneurysm or false aneurysm of the interauricular septum disclosed by 2 cerebral embolisms]. / Anévrysme ou faux anévrysme du septum interauriculaire, révélé par deux embolies cérébrales.

The authors report a case of solitary aneurysm of the interatrial septum documented by ultrasonography and angiography and revealed by two transient cerebral ischaemic accidents unexplainable by other causes. At surgery, performed later, the interatrial septum was redundant, and Botallo's foramen was about 17 millimetres in diameter, but no sacciform cavity was found. The reasons for the discrepancy between imaging techniques and operative findings and the mechanism of systemic embolism are discussed.

[Effects of nifedipine on carotid blood flow and baroreflex response in essential arterial hypertension. Preliminary results]. / Effet de la nifédipine sur le débit carotidien et la réponse baroréflexe, au cours de l'hypertension artérielle essentielle. Résultats préliminaires.

The objective of this prospective study was to evaluate the effect of nifedipine administered at usual daily doses of 30 to 40 mg on the carotid flow in arterial hypertension. The study included 15 patients (8 men and 7 women), 50 to 79 (mean 59.5) years old suffering from long-standing, fixed essential hypertension becoming instable under central antihypertensive drug therapy. For calculating the carotid blood flow, vascular echotomography combined with Doppler ultrasonography and spectral analysis (Duplex probe) determining the vascular section and flow velocity were used. Arterial pressure using a mercury tonometer, flow velocity, common carotid artery diameter, carotid blood flow, Pourcelot's index, parietal tension and heart rate were measured before treatment and at the 8th day of nifedipine administration. It could be shown that the drug produced a significantly (p less than 0.001) increased carotid blood flow, in spite of a marked (p less than 0.001) decrease in systolic (p less than 0.001) and diastolic (p less than 0.005) blood pressure. The increase in carotid blood flow was directly related to the increase in flow velocity (p less than 0.001) and in the diameter of common carotid artery (p less than 0.01) and was associated with a significant decrease in the Pourcelot's index. Analysis of two groups of patients isolated from the total group according to the elevation of carotid blood flow, showed that the degree of hypotensive effect of nifedipine is negatively correlated with the baroreflex response determined by the variation of parietal tension.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic monitoring of Marfan's syndrome. Triple valvular prolapse and calcified permeable foramen ovale]. / Suivi échocardiographique d'un syndrome de Marfan. Triple prolapsus valvulaire et foramen ovale perméable calcifié.

A patient with typical Marfan's syndrome was monitored by echocardiography, which detected (in 1978) a prolapse of the mitral valve complicated by severe cardiac insufficiency, necessitating valve replacement. Seven years later an aneurysm of the ascending aorta (60 mm) was detected which caused prolapse of the aortic valve with valvular insufficiency, combined with prolapse of the tricuspid valve and a calcified foramen ovale the permeability of which was verified by peripheral injection of contrast medium. Echocardiography, notably two-dimensional, is an excellent examination for regular and atraumatic monitoring of Marfan's syndrome and detection of cardiovascular complications.

[Acute renal ischemia caused by medically reversible embolism of iatrogenic origin]. / Ischémie rénale aiguë par embolie d'origine iatrogène réversible médicalement.

The authors present a case of acute renal ischemia resulting from embolism of its main artery on the occasion of the transient interruption of anticoagulant treatment for dental extraction, in a patient bearing a Björk-Shiley valvular prosthesis in the mitral position. Its progression is marked by the complete repermeabilisation of the artery under heparin therapy with complete recuperation of renal function. This classically exceptional observation suggests that the delay occurring between the initial obstruction and repermeabilisation does not alter the degree of renal distress, the estimation of which is unpredictable. The relative resistance of the kidney to ischemia and the occurrence of efficacious fibrinolysis suggests the possibility of therapy other than surgery. Prevention demands the maintenance of coagulants under guarantee of local hemostatic processes.

[Risk factors in the combination of myocardial infarction and carotid atheroma]. / Les facteurs de risque dans l'association infarctus du myocarde-athérome carotidien.

This study compares two groups of patients: Group I with 44 patients who suffered recent acute myocardial infarction and Group II: 40 control subjects. In both groups, 2D Doppler echocardiography was performed to detect carotid atheroma, to determine the respective roles of vascular risk factors for two sites of atherosclerosis. Carotid atheroma affected 73 p. 100 of subjects in Group I and 22.5 p. 100 in Group II. Carotid stenosis of more than 40 p. 100 was found mainly in hypertensive patients who presented with acute myocardial infarction, and in patients with left ventricular hypertrophy. Smoking was more frequent in Group I than in Group II (p less than 0.001) irrespective of the frequency of carotid atheroma (p less than 0.05). Hypercholesterolaemia only favoured carotid atherosclerosis after acute myocardial infarction (p = 0.01). We did not find any difference in the incidence of diabetes mellitus in the two groups of patients. Age analysis indicated that carotid atheroma occurred earlier in Group I than in Group II. An association between a dominant risk factor for coronary disease (smoking or hypercholesterolemia) was found in 9 patients, all of whom had severe bipolar atherosclerosis with multivessel coronary lesions and carotid stenosis.

[Quantification of carotid atheroma, by vascular ultrasonics and spectral analysis, after myocardial infarction. Apropos of 80 cases]. / Quantification de l'athérome carotidien, par l'échotomographie vasculaire et l'analyse spectrale, après infarctus du myocarde. A propos de 80 observations.

A prospective study of carotid artery atheroma by vascular echotomography and spectral analysis was performed in 40 patients with myocardial infarction and 40 control subjects. Carotid artery atheroma was commoner in the group of patients with myocardial infarction (72.5% +/- 6.8%), earlier (9 years), more commonly bilateral (37.5% +/- 7.6%) and more stenotic (32.5% +/- 7.4%) than in the control group (p less than 0.000a, p less than 0.0001 and p less than 0.002, respectively). The severity of carotid artery atheroma correlated with the site of coronary artery disease; the following significant relationships were found: stenosing 40% and/or bilateral carotid atherosclerosis and left anterior descending disease (p less than 0.02); carotid atherosclerosis and double or triple vessel disease (p less than 0.05). The authors conclude that detection of carotid artery atheroma after myocardial infarction is valuable for two reasons: it gives an indication as to the severity of the coronary disease; carotid endarterectomy may be considered at the same time as coronary artery bypass surgery.

[Cardiac manifestations of chronic atrophic polychondritis]. / Les manifestations cardiaques de la polychondrite chronique atrophiante.

The authors present a case of chronic atrophic polychondritis with cardiovascular complications, consisting of aortic incompetence due to dilatation of the aortic ring associated with an aneurysm of the ascending aorta and a first degree atrio-ventricular block occurring six months after the onset of the disease. The progression towards heart failure resulted in the replacement of the ascending aorta and of the aortic valve. The authors discuss the cardiovascular complications of this disease.

[Diagnosis and echocardiographic course of infectious endocarditis in obstructive cardiomyopathy]. / Diagnostic et évolution échocardiographiques d'une endocardite infectieuse sur cardiomyopathie obstructive.

A typical case of advanced obstructive cardiomyopathy in a young subject was revealed by Streptococcal mitral valve endocarditis and was diagnosed by one and two dimensional echocardiography, which revealed a pedunculated vegetation on the large mitral valve and rupture of the chordae of the small mitral valve. This was complicated by biventricular heart failure, peripheral arterial embolism in the leg due to migration of the vegetation which disappeared on the repeat echocardiography and pulmonary embolism with arterial clot emboli due to heparin-induced thrombocytopenia. This condition resolved without requiring cardiac surgery. Patients with obstructive cardiomyopathy should be treated routinely with prophylactic antibiotics, particularly when dental treatment is required. Echocardiography has become an essential examination in the diagnosis of this disease and its complications, especially in cases with infectious endocarditis.

[Cardiac insufficiency in infectious endocarditis]. / L'insuffisance cardiaque dans l'endocardite infectieuse.

The aim of this study of 101 cases of infective endocarditis was to determine the factors predisposing to cardiac failure, the prognostic factors of this complication and the therapeutic implications. A significant (p less than 0.05) Chi square test was the statistical reference. Fifty-two per cent of patients developed cardiac failure which was biventricular in 48 p. 100 of cases and the presenting symptom in 64 p. 100. The mean age of the patients with cardiac failure was 56.6 years with a clear male predominance. In 48 p. 100 of cases, cardiac failure complicated a pre-existing cardiac lesion which was usually acquired (84 p. 100). The commonest condition was valvular insufficiency of the aortic and mitral valves (70 p. 100 of cases with cardiac failure). Severe cardiac failure was observed more frequently and earlier in aortic than in mitral regurgitation. The commonest infecting organism was the streptococcus (53 p. 100 of cases with cardiac failure) and the most frequent presumed portal of entry was dental (25 p. 100). Arrhythmias were observed in 51 p. 100 of patients in cardiac failure, the commonest being atrial fibrillation (34 p. 100) complicating mitral valve disease in 56 p. 100 of cases; 17 p. 100 of arrhythmias were ventricular. Conduction defects were observed in 26 p. 100 of cases with cardiac failure, 55 p. 100 of which had aortic valve disease. Valvular vegetations were demonstrated by echocardiography in 43 p. 100 of cases with cardiac failure. Valve replacement had to be performed for resistant cardiac failure in 13 p. 100 of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac complications of infectious endocarditis]. / Les complications cardiaques des endocardites infectieuses.

Factors predisposing to cardiac complications and influencing hospital survival, were analysed in a retrospective study of 101 cases of infective endocarditis. Heart failure occurred in 52 p. 100 of our patients. A significantly greater incidence of heart failure was observed in endocarditis with no preexisting heart disease (p less than 0.01), aortic and mitral valve involvement (p less than 0.01), staphylococcus aureus infections (p less than 0.05), arrhythmias (p less than 0.001), and conduction disturbances (p less than 0.01). Significantly more patients with congestive cardiac failure died in hospital (51 p. 100) than those without congestive cardiac failure (17 p. 100) (p less than 0.001). Severe heart failure before treatment (p less than 0.05), streptococcus D endocarditis (p = 0.05), supraventricular arrhythmias (p less than 0.05), and intracardiac conduction disturbances (p less than 0.05), significantly increased the hospital mortality in patients with congestive heart failure. Electrocardiographic findings revealed arrhythmias in 34 p. 100 of cases, more commonly with mitral valve involvement (71 p. 100) and 52 p. 100 died in hospital. The development of intracardiac conduction disturbance during the course of 18 cases of endocarditis (aortic valve in 11 cases) was associated with a hospital mortality rate of 60 p. 100. The incidence of pericarditis and pulmonary embolism was 4 and 7 p. 100 respectively, and all patients died in hospital. Acute inferior myocardial infarction compatible with coronary embolism was suspected in one patient. Early cardiac valve replacement improved the hospital survival in patients with cardiac complications of infective endocarditis.

[Current aspects of infectious endocarditis. Review of 101 cases]. / Aspects actuels des endocardites infectieuses. Revue de 101 observations.

One hundred and one cases of infectious endocarditis were reviewed, from 1966 to 1982. The mean age of the patients was 56.3 +/- 15 years. There was a marked predominance of men (70.2 p. 100); the commonest portal of entry was dental (45.9 p. 100); the number of iatrogenic portals of entry and cases of endocarditis on prosthetic valves has been increasing in recent years. Blood cultures were positive in 83 p. 100 of cases; the commonest responsible organism was the non-D streptococcus (31 p. 100 of cases) followed by the D streptococcus (18.8 p. 100), the staphylococcus aureus (17.8 p. 100), and the staphylococcus epidermidis (2.9 p. 100). Gram-negative bacilli were isolated in 9.9 p. 100 of cases. Rare and slow growing organisms have been isolated since 1977. Echocardiography was then introduced and helped the diagnostic in 70 p. 100 of cases. Circulating immune complexes were measured in 25 patients and were found to be raised in 14 cases (56 p. 100). The commonest complication was cardiac failure (43 p. 100) which led to valve replacement in the acute phase in 14 p. 100 of cases. The occurrence of cardiac arrhythmias was a poor prognostic factor. The other complications were neurological (15 p. 100), renal (10 p. 100), embolic (19 p. 100), and pulmonary (9 p. 100). The mortality rate in the acute phase was 30 p. 100 and the probability of a five year survival was 54 p. 100.

[Infectious endocarditis in the elderly]. / L'endocardite infectieuse chez les sujets âgés.

Thirty three cases of infectious endocarditis in patients over 65 years of age (mean age: 72,5 years) observed between 1966 and 1982, were analysed; there were 22 male and 11 female patients, a male predominance of 67%. The data was compared with 68 cases of patients aged less than 65 years of age (mean age: 48,4 years; 49 male and 19 female patients, a male predominance of 72%) treated during the same period. In the patients over 65 years old, compared to those under the age of 65, we observed that: the previous condition of the cardiac valves was more commonly unknown (39% compared to 21%), rheumatic valvular disease was rare (12% of cases), the diagnosis was not delayed, the reason for hospital admission was usually a complication (30% compared to 7%), the two cardinal signs (pyrexia and a cardiac murmur) were always present, as in the younger age group, the urinary tract was the only commoner site of primary infection, the blood cultures were as frequently positive in both groups (79% compared to 85%), in cases with negative blood cultures, antibiotics had not always been given beforehand, but this was commoner than in the younger age group, the causal organisms and usual biological changes were unremarkable, echocardiography, often more difficult because of the high incidence of valvular thickening, remained a valuable tool for diagnosis and management, cardiac failure was more common (55% compared to 37%) as were neurological complications (24% compared to 10%) and renal failure, mortality was greater (39% compared to 25%) and higher in both groups in patients with aortic valve disease and infection with staph-aureus.

Rheumatological manifestations of infective endocarditis.

A retrospective study showed musculoskeletal manifestations in 32 of 108 patients treated for infective endocarditis in several departments at the Poitiers CHU. Such manifestations included articular pain or aseptic arthritis, typically involving the major joints, as well as vertebral osteomyelitis, low back pain (inflammatory or non-inflammatory), and myalgia. Patients showing such signs were generally younger than those without musculoskeletal involvement, diagnosis was made later, and prognosis was worse; streptococcus D was more often involved, and microscopic haematuria was more common. With the exception of vertebral osteomyelitis, the pathogenesis was not clear.