[Calculation of the regurgitation fraction in mitral insufficiency by Doppler echocardiography using a study of the zone of flow convergence]. / Calcul de la fraction de régurgitation des insuffisances mitrales en échocardiographie Doppler par étude de la zone de convergence.

The aim of this study was to propose a new method for calculating the regurgitation fraction of mitral insufficiency by the proximal isovelocity surface area (PISA) method and to compare it with the value of the catheter regurgitation fraction. Thirty-five patients (21 men and 14 women) aged 59 +/- 13 years with isolated mitral insufficiency were studied. Analysis of the proximal isovelocity surface area enabled calculation of an instantaneous maximum regurgitant flow, surface of the regurgitant orifice and the regurgitant volume. The regurgitant fraction was calculated by dividing the regurgitant volume by the sum of the regurgitant volume and aortic stroke volume measured by Doppler echocardiography. These parameters were compared with the corresponding catheter data and the angiographic grade of mitral insufficiency. The echocardiographic and catheter studies were performed within 1.7 +/- 1.2 days. There was a statistically significant correlation between the instantaneous maximum regurgitant flow calculated by the PISA method and the catheter regurgitant flow (r = 0.88; p = 0.0001); between the regurgitant volume calculated by the PISA method and the catheter regurgitant volume (r = 0.85; p = 0.0001) and the regurgitation fraction calculated by the PISA method and the catheter regurgitant fraction (r = 0.82; p = 0.0001). A regurgitant fraction by the PISA method of > 45% corresponded to severe mitral regurgitation (> or = angiographic grade 3 and/or a catheter regurgitant fraction > or = 50%) with a sensitivity of 88% and a specificity of 100%. The PISA method should form part or routine quantification of mitral insufficiency.

[Myocardial infarction caused by thrombosis of the left coronary artery in a patient with thrombocythemia]. / Infarctus du myocarde par thrombose du tronc commun de la coronaire gauche chez un patient thrombocytémique.

Myocardial infarction is not exceptional in patients with essential thrombocythaemia. This infarction is often related to the formation of in situ coronary thrombosis with no associated atheromatous lesions. The authors report the case of a thrombocythaemic patient with anterior infarction due to thrombosis of the left coronary artery. The clinical course is often more severe than in nonthrombocythaemic patients. The pathophysiological mechanisms remain unclear, but appear to be related to qualitative rather than quantitative platelet abnormalities.

Echocardiographic demonstration of intracardiac glue after endoscopic obturation of gastroesophageal varices.

Systemic embolism is an unusual complication of endoscopic obturation of gastroesophageal varices with glue. This report describes a case of cerebral embolism after this procedure. Intracardiac glue within the left atrium was demonstrated by echocardiography. Cardiac fluoroscopy demonstrated an abnormal vessel connecting periesophageal veins with the right upper pulmonary vein. Cardiac surgery was performed. Intracardiac glue was removed and the entering orifice of the abnormal vessel in the right upper pulmonary vein was sutured. To our knowledge, this is the first reported case of intracardiac glue after variceal obturation. Echocardiography is useful in the diagnosis of this rare complication.

[Left ventricular dilatation after primary transmural anterior myocardial infarction. Influence of the percentage of akinesia on echocardiography]. / Dilatation ventriculaire gauche après primo-infarctus antérieur transmural: influence du pourcentage d'akinésie en échographie.

The aim of this study was to determine whether the percentage of akinesia on echocardiography during the acute phase of transmural anterior myocardial infarction could predict secondary left ventricular dilatation. The study group comprised 24 patients (18 men and 6 women) with an average age of 59 years. The patients underwent two echocardiographic examinations, the first during the acute (< 72 hours) phase and the second, 6 months later. Ventricular volumes were calculated by the ellipse monoplane method in the apical 4 chamber view. The percentage of akinesia was defined as the ratio between the length of the akinetic segment and the left ventricular end diastolic perimeter in the apical 4 chamber view. An increase in end diastolic volume (83 +/- 25 vs 62 +/- 18 ml/m2; p < 0.01) and in end systolic volume (51 +/- 27 vs 34 +/- 11 ml/m2; p < 0.01) was observed 6 months after infarction without a significant change in ejection fractions (42 +/- 17% vs 44 +/- 10%). The percentage of akinesia in the acute phase was > 30% in 15 patients (Group I) and < 30% in 9 patients (Group II). The increase in ventricular volumes at 6 months after infarction was significant in Group I (p < 0.02) but not in Group II. At 6 months after infarction, the end systolic volumes were greater (60 +/- 27 vs 37 +/- 22 ml/m2, p < 0.5) and the ejection fractions were lower (35 +/- 13% vs 53 +/- 18%, p < 0.01) in Group I than in Group II.(ABSTRACT TRUNCATED AT 250 WORDS)

[Myocardial bridge of the left anterior descending coronary artery and myocardial infarction: does coronary spasm play a part?]. / Pont myocardique de l'artère interventriculaire antérieure et infarctus du myocarde. Le spasme coronaire a-t-il un rôle?

The association of a myocardial bridge of the left anterior descending (LAD) coronary artery and myocardial infarction is rare. The mechanisms by which the myocardial bridge could predispose to myocardial infarction are tachycardia (reducing the duration of diastolic coronary filling), thrombosis at the site of the myocardial bridge, and coronary spasm which, however, has never been demonstrated in the context of infarction. The aim of this study was to detect coronary spasm by provocative ergometrine testing in 4 patients, all male, aged 21 to 49 years, average 39 years old, who had anterior myocardial infarction associated with myocardial bridging of the LAD artery without atheromatous coronary stenosis. The ergometrine tests were performed during (2 cases) or after coronary angiography (2 cases). The systolic narrowing due to the myocardial bridge ranged from 25 to 95% (average 70%). The ergometrine test was strongly positive in 1 patient and negative in the other 3. Repermeabilisation of a thrombus was suggested in these 3 patients by the recording of an accelerated idioventricular rythm in the acute phase of infarction (2 cases) or by the demonstration of abnormal platelet aggregation (1 case). This is the first report of coronary spasm in a patient with myocardial bridging associated with infarction. However, it is not possible to determine the respective roles of spasm and myocardial bridging in the genesis of the infarct. We suggest systemic provocative ergometrine testing in this situation to orientate the most appropriate treatment.

[Evaluation of pulmonary arterial hypertension by Doppler echocardiography in chronic respiratory insufficiency]. / Evaluation de l'hypertension artérielle pulmonaire par échocardiographie doppler dans l'insuffisance respiratoire chronique.

The usefulness of doppler-echocardiography for the assessment of pulmonary arterial hypertension in patients with chronic respiratory failure was evaluated in 24 consecutive patients with chronic obstructive lung disease. Seventeen of these 24 patients (71 p. 100) who had tricuspid valve regurgitation analysable by the continuous wave doppler technique were selected as study group; they included 15 men and 2 women aged from 33 to 78 years (mean 63 years). The highest maximum velocity value (method A) or the maximum velocity value averaged on several cycles (method B) of the tricuspid regurgitation jet was used to calculate the right ventriculo-atrial pressure gradient, using Bernouilli's equation. Right atrial pressure was determined by three methods: haemodynamic measurement, clinical evaluation or attribution of an arbitrary 10 mmHg value. The pulsed doppler study of the pulmonary ejection flow included measurement of the acceleration time and calculation of the acceleration time/ejection time ratio. The usual echocardiographic parameters were measured. Catheterization was performed 2.5 days on average after the doppler study. Correlations between doppler examination and catheterization to evaluate the right ventricular systolic pressure were significant (p less than 0.001) and better with method B than with method A. Depending on the method employed to evaluate the right atrial pressure, the correlation coefficients obtained with method B were: 0.93 (haemodynamic measurement), 0.91 (clinical evaluation) and 0.88 (arbitrary value of 10 mmHg). The right ventricular systolic pressure evaluated by doppler ultrasound using method B and by clinical evaluation of the right atrial pressure was 47 +/- 12 mmHg (22 to 70 mmHg), as against 51 +/- 13 mmHg (28 to 74 mmHg) measured by catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

[Myocardial infarction during or after exertion related to sports. Clinical and coronary angiographic analysis of 10 cases]. / Infarctus myocardique au cours ou décours de l'effort sportif. Analysis clinique et coronarographique de 10 cas.

The purpose of this study was to analyse characteristic of myocardial infractions that occur during, or immediately after sport-related exertion in subjects who are neither athletes nor professional sportsmen and who undergo coronary angiography. Ten cases where myocardial infraction developed during (n = 3) or immediately after (n = 7) a game were studied retrospectively. All patients were men aged from 21 to 61 years (mean 48.8 years); 8 of them were smokers and 5 had hypercholesterolaemia. The sports practised were tennis (3), cycling (2), football (2), skiing (2) and weight-lifting (1). The infarction was inferior or basal in 5 cases, lateral in 1 case and anterior or anteroseptal in 4 cases. Coronary lesions involved one vessel in 6 and two vessels in 2 patients aged from 47 to 61 years. They were absent in 2 patients aged 24 and 26 respectively, with methylergonovine-induced spasm in one case. The outcome over a 2.9 years follow-up period was favorable, except for one death 6 months after the infarction (patient aged 24, normal coronary arteries, spasm). The outstanding features in this study are: (1) the occurrence of infraction during the recovery period and the noxious role played by smoking; (2) the contrast between the presence of atherosclerotic coronary lesions in middle age subjects and their absence in younger subjects (infarction due to spasm or thrombosis?), and (3) the possible usefulness of an exercise test in sport players of more than 40 years of age.

[Acquired systemo-pulmonary fistula after pleurectomy responsible for a continuous thoracic murmur]. / Fistule systémo-pulmonaire acquise après pleurectomie responsable d'un souffle thoracique continu.

Systemo-pulmonary fistulae are rare. The case of a 27 year-old man, hospitalized for exploration of a continuous thoracic murmur, is reported. A right pleurectomy had been performed 2 years previously because of a recurrent spontaneous pneumothorax, and no murmur was present at that time. Angiography showed a systemo-pulmonary fistula with the right internal mammary artery and branches of the right axillary artery as afferent vessels, and the right pulmonary arteries and veins as efferent vessels. Blood gases measurements demonstrated a left-right shunt. The acquired nature of the fistula was suspected because of the history of right pleurectomy and the acquired nature of the murmur. There was no indication for surgery because of the complexity of the fistula and the absence of symptoms.

[Intrapulmonary right-left shunt associated with liver cirrhosis: diagnosis by contrast echocardiography]. / Shunt droit-gauche intrapulmonaire associé à une cirrhose hépatique: diagnostic par échocardiographie de contraste.

The hypoxaemia associated with hepatic cirrhosis is classically attributed to an intrapulmonary shunt caused by small vascular abnormalities. Severe hypoxaemia (47 mmHg) associated with dyspnoea, cyanosis and clubbing was observed in a 57-year old man who presented with cirrhosis of the liver. At contrast echocardiography, a right-to-left shunt was demonstrated by the appearance of microcavities in the left atrium and ventricle after peripheral intravenous injection of the contrast medium. The intrapulmonary location of the shunt was determined by a 4 cardiac cycles interval between the arrival of the microcavities in the right heart and their appearance in the left heart. The right-to-left shunt was confirmed by the pure oxygen ventilation test and by pulmonary perfusion scintigraphy with radiolabelled albumin microaggregates. Pulmonary angiography proved normal. Thus, contrast echocardiography is capable of diagnosing right-to-left shunts associated with hepatic cirrhosis and to demonstrate their intrapulmonary location.

[Postpartum myocardial infarction with normal coronary arteries. Apropos of a case]. / Infarctus du post-partum à coronaires saines. A propos d'un cas.

A case of painless anteroseptal and high lateral wall infarction presenting as cardiogenic shock with pulmonary oedema 24 hours after childbirth complicated by severe post partum haemorrhage with a coagulation defect, is reported. Coronary angiography performed one month later was normal, with a negative ergometrine provocation test. The authors review five previous reports in the medical literature, and discuss the possible physiopathological mechanisms which, alone or in association could have operated in the reported case.

[Circumflex artery originating from the right anterior sinus of Valsalva: benign anomaly or a factor in myocardial ischemia? Apropos of 2 cases]. / Artère circonflexe née du sinus de Valsalva antéro-droit: anomalie bénigne ou facteur d'ischémie myocardique? A propos de 2 cas.

The abnormal formation of the circumflex artery from the right anterior sinus of Valsalva is generally considered benign and without any particular ischemic risk. Two cases are reported of myocardial ischemia in the region of the abnormal artery. In both cases an unstable angina was associated with objective criteria (electrocardiographic and isotopic) of myocardial ischemia. In one case the circumflex artery presented marked proximal stenosis compatible with the development of accelerated atherosclerosis. In the other case the circumflex artery was free of any stenosis and the ischemic manifestations observed seem to be due to the abnormal origin of the vessel only. Certain cases of the circumflex artery anomaly can, therefore, be complicated by myocardial ischemia, and the benign nature of the anomaly needs to be re-examined.

Atrial septal aneurysm--a potential cause of systemic embolism. An echocardiographic study.

Atrial septal aneurysm is an uncommon condition. Between 1981 and 1984 10 cases of atrial septal aneurysm were diagnosed by real time cross sectional echocardiography performed in 4840 patients. The aneurysm was associated either with mitral valve prolapse (three patients) or with atrial septal defect (three patients) or occurred in isolation (four patients, two of whom had had a previous embolic event leading to the diagnosis of atrial septal aneurysm by cross sectional echocardiography). During cross sectional echocardiography the aneurysm appeared as a localised bulging of the interatrial septum, which was best seen in the subcostal four chamber view and in the parasternal short axis view at the level of the aortic root. The aneurysm either protruded into only the right atrium (five patients) or moved backwards and forwards between the right and the left atria during the cardiac cycle (five patients). This motion pattern might be related to changes in the interatrial pressure gradient. The two patients who had had a systemic embolism were given anticoagulant treatment, but none underwent surgery. It is concluded that the true prevalence of atrial septal aneurysm might have been underestimated before the routine use of cross sectional echocardiography, that cross sectional echocardiography enables definitive diagnosis of this condition by a non-invasive technique, and that an atrial septal aneurysm should be suspected and looked for by cross sectional echocardiography after an unexplained systemic embolism.

[Myocardial infarction in the young subject: a medium-term clinical and coronary angiographic study in 40 patients under 36 years of age. Comparison with coronary angiographic data of myocardial infarction in patients after 50 years of age]. / L'infarctus myocardique du sujet jeune: étude clinique et coronarographique à moyen terme de 40 patients de moins de 36 ans. Comparaison avec les données coronarographiques de l'infarctus myocardique après 50 ans.

A series of 40 myocardial infarctions, occurring in patients under 36 years of age was studied retrospectively (Group I: mean age 31.3 years). The medium term results of coronary angiography in this group were compared with those of 60 myocardial infarctions after 50 years of age (Group II: mean age 56.6 years). Group I had a clear male predominance (92.5%), a high incidence of smoking (69%), hypercholesterolaemia (69%); myocardial infarction was the first manifestation of their disease in 54% and it was often extensive (42%). A comparative angiographic study between the two groups showed: 1) Less widespread lesions in Group I, as assessed by the number of main arteries stenosed (p less than 0.001), the coronary index (p less than 0.01) and the mean coronary score using Friesinger's method (p less than 0.01). 2) A higher incidence of subnormal coronary angiogrammes in Group I (absence of 50% stenosis) (15%) and of single vessel disease (40%): compared with Group II in which multivessel disease was observed in 86.5% of cases. 3) Collateral circulation was less common in Group I (p less than 0.01). On the other hand, a comparative study of regional and global left ventricular function showed no difference between the two groups. Two subgroups were distinguished in Group I: in one subgroup, multiple lesions similar to those found in Group II, suggestive of premature coronary atherosclerosis (52.5%); the other group (47.5%) presented unilocular lesions i.e. focal mono-arterial lesions compatible with other causes of infarction (thrombosis and/or spasm). These patients were younger (p less than 0.05) and had significantly fewer cardiovascular risk factors (p less than 0.01). Despite the fact that the coronary lesions were limited, the myocardial damage was comparable with the other groups as the collateral circulation was much less developed (p less than 0.02). These appearances were only observed in 3.5% of patients in Group II. The study of the angiographic outcomes of these two types of lesions should show a difference and could contribute to the understanding of their mechanisms.

[Coronary arteriography and long-term prognosis in postero-inferior infarction. Methodological reflections apropos of a preliminary retrospective survey]. / Artériographie coronaire et pronostic à long terme des infarctus postéro-inférieurs. Réflexions méthodologiques à propos d'une enquête rétrospective préliminaire.

Most studies of the long term prognosis after myocardial infarction take only parameters reflecting the quantity of necrosed cardiae muscle and the resulting disturbances in left ventricular function into account. Coronary arteriography should give a more precise assessment by the detection of stenoses on arteries supplying healthy myocardium, especially in small infarcts. This concept was tested in a retrospective study of 100 patients investigated 1 to 12 months after inaugural posterior or inferior myocardial infarction between 1970 and 1979, and followed-up for an average of 32,5 months. THe survival curves of subgroups defined by angiographic parameters were compared by Mantel's method. The 5 year survival rate was 91,2 +/- 3,4%, corresponding to a mortality of 26 deaths per 1000 patients year. This very low mortality rate may be related on the one hand to the selection of the patients, especially those investigated at a distance from the infarct, and on the other hand, to the role of drug therapy. The number of patients required to compare two therapeutic protocols would be necessarily high because of the low overall mortality. The 5 year survival rate without a serious cardiac event (death, recurrent infarction, deterioration to Stages III or IV of the NYHA Classification, acute coronary insufficiency), was 76,8 +/- 6.4%. The only discriminating angiographic sign in this study was the number of diseased vessels: triple vessel disease significantly increased the risk of a serious cardiac event, (p less than 0,04). The preliminary results have led to the establishment of a stricter protocol designed to improve the indications of coronary arteriography in postero-inferior infarction.

[Hemodynamic and angiographic aspects of endomyocardial fibrosis. Apropos of 19 cases]. / Aspects hémodynamiques et angiographiques des fibroses endomyocardiques. A propos de 19 observations.

19 cases of endomyocardial fibrosis were studied. Angiocardiography localises the site of fibrosis and seems to be the best diagnostic method. All cases in this series had left ventricular involvement which resulted in changes of the silhouette (square, polylobulated or deformed like the shape of a heart on a playing card) and of the ventricular contour (smooth, lacunar or "doubled"). Ten patients had mitral incompetence. The ejection fraction was normal in 8 patients but significantly reduced in the series as a whole (EF = 0,56, p less than 0,05). 15 patients had right ventricular involvement. Apart from the smooth contour of the anterior wall, the only abnormality in the mild cases, the most suggestive feature was an amputation of the ventricular apex, giving rise to a ventricular appearance of a narrow, akinetic (apart from the infundibular region) tube. The catheter data demonstrated the haemodynamic changes due to the fibrosis. A constrictive syndrome was observed in all the severe poorly tolerated cases. This was not apparent under basal conditions in milder cases. The value of pharmacodynamic testing and endomyocardial biopsy in cases where the diagnosis is uncertain should be stressed. The results of resection of the fibrosis and valvular replacement in severe cases depend to a large extent on the degree of myocardial involvement.

[Long-term results of aortocoronary bypass. 2 Angiographic aspects]. / Résultats à long terme des pontages aorto-coronaires. 2. Aspects angiographiques.

Follow-up arteriograms carried out between one and six years (mean follow-up period two years) in 80 cases of aorto-coronary bypass graft procedures showed a good correlation between the quality of the clinical results obtained -- as detailed in the first part of this article -- and a larger proportion of patent grafts: 82% of 130 grafts had remained patent, and 94% of patients have all or some of their grafts patent. Late occlusion of the grafts is rare, and does not appear to be influenced by abnormalities of the graft found at early follow-up, these abnormalities being fairly stable. These follow-up have especially shown the good correlation between the quality of the clinical results and the functional status of the coronary network in the long term, a function not only of the permeability of the grafts which have been carried out, but also of the complete or incomplete correction of the lesions of the three coronary trunks. Such a complete procedure which was carried out or could have been carried out in only 30% of the total patients, was then successful in 94% undergoing it. The clinical results should therefore lead us to carry out operations which remove the lesions as completely as possible.