[When should mitral valve prolapse be considered a real disease?]. / Quand doit-on considérer le prolapsus valvulaire mitral comme une véritable affection?

Mitral valve prolapse should be considered as a disease when superior displacement of the mitral leaflets during systole is more than 2 mm with a maximal leaflet thickness of at least 5 mm. Using these criteria, the prevalence of mitral valve prolapse is 1.3% in the general population, nearly the same in men and women. Serious complications may occur during follow-up with a 1 to 3% patient-year risk. The most important complication is mitral regurgitation, mainly due to rupture of the chordae tendineae, which must be quickly corrected by surgical repair. Second is infective endocarditis, a complication which may occur particularly in men older than 45 years of age with systolic murmur. Arrhythmias are not infrequent but ischemic neurologic events are unusual, especially in young patients. Cases of sudden death have occasionally been reported.

Sleep apnoea syndrome and the extent of atherosclerotic lesions in middle-aged men with myocardial infarction.

BACKGROUND: To determine whether extended atherosclerotic lesions are correlated to the presence of sleep breathing disorders. EXPERIMENTAL DESIGN: A prospective clinical study. SETTING: A tertiary regional referral center. PATIENTS: 40 male patients < or =65 years consecutively admitted to the cardiac care unit for an acute myocardial infarction with serous creatinine phosphokinase (CPK) > or =350 IU/l and a CPK-MB fraction > or =10%. Exclusion criteria were: cardiac surgery on emergency, stroke, major neurological and/or psychiatric disturbances, alcohol consumption >50 g/day, toxicomania, clinical or biological hypothyroidism, clinical acromegaly and chronic obstructive pulmonary disease. MEASURES: Duplex ultrasonography was performed on carotid arteries, femoral arteries and their bifurcations. An overnight polysomnography was performed after hospital discharge. Patients with an apnoea index >5/hour or apnoea-hypopnea index >10/hour of sleep are considered to have sleep apnoea syndrome (SAS). Patients with additive peripheral atherosclerotic lesions are compared to patients with normal carotid and femoral arteries, regarding to standard cardiovascular risk factors and apnoeas or hypopnoeas during sleep. RESULTS: Duplex revealed in 18 patients carotid and/or femoral atherosclerotic lesions. The prevalence of SAS in patients with at least one peripheral arterial lesion was significantly higher (61% vs 18%, p<0.01). A nearly significant difference was also noted in patients with carotid lesions alone compared to those with normal carotid arteries (57% vs 27%, p=0.06). CONCLUSIONS: These results suggest a possible link between sleep breathing disorders and the pathogenesis of atherosclerotic lesions.

[Radiofrequency ablation in auricular flutter. Predictive factors of primary success and medium term results]. / Ablation par radiofréquence du flutter auriculaire. Facteurs prédictifs du succès primaire et devenir à moyen terme.

Ninety-one consecutive patients underwent radiofrequency ablation of chronic or paroxysmal atrial flutter. The average age of the patients was 66. There was a previous history of atrial fibrillation in 38% of cases and of cardiac surgery in 14.3% of cases. The primary success rate was 79% (92% in cases of common flutter). The predictive factors of success were the type of flutter (p < 0.001), left ventricular (p < 0.01) and left atrial dimensions (p < 0.01) at echocardiography. The length of the cavo-tricuspid isthmus measured by echocardiography had no influence on the initial result but, in primary success, did affect the parameters of the procedure (duration and number of applications of radiofrequency energy). After an average of 11 +/- 2 months, sinus rhythm was maintained in 67% of patients. There were recurrences of flutter in 27.5% of cases and of atrial fibrillation in 5.5% of cases: 85% of these episodes occurred during the first six months after ablation. A second procedure was carried out in 12 patients for recurrence of flutter (92% primary success rate). After an average follow-up of 8.4 months, 4 patients had a recurrence and required a third procedure (100% success rate). In cases of failure of ablation, the rhythm was converted by a shock or atrial pacing: 47.3% of these patients remained in sinus rhythm with antiarrhythmic therapy with a 12 month follow-up. Radiofrequency ablation of atrial flutter is, therefore, a safe method, the difficulty of which is mainly related to anatomical factors: the medium-term results are better than those of other therapeutic methods.

[Predictive factors of smoking cessation after myocardial infarction. Review of the literature]. / Facteurs prédictifs de l'arret du tabac apres un infarctus du myocarde. Revue de la littérature.

This paper reviews the current state of knowledge about smoking after myocardial infarction in smokers. After presenting results emphasizing the value of post-infarction smoking cessation, all of the predisposing factors to smoking cessation are analysed. The objective of this review of the literature is to recognize these factors in order to more precisely define the various medical, psychological and social aspects of an assistance programme adapted to post-infarction smoking cessation.

[Lactobacillus acidophilus endocarditis]. / Endocardite à Lactobacillus acidophilus.

BACKGROUND: Lactobacillus is a commensal germ found in the buccal cavity, the digestive tract and the vagina. Usually non-pathogenic except in case of dental caries, it can occasionally be the causal agent in severe endocarditis. CASE REPORT: A 70-year-old woman developed endocarditis on an aortic valve bioprosthesis. Lactobacillus acidophilus was isolated from blood cultures of the valve after surgery. COMMENTS: Forty-four cases of Lactobacillus endocarditis have been reported in the literature to date. Mortality is high (26%). The main difficulty in treatment is germ tolerance to penicillin and aminosides found in all cases. Cure requires high dose parenteral antibiotics and surgery in many cases (26%).

[Ostial stenosis of the common trunk of the left coronary artery 20 years after mediastinal irradiation]. / Sténose ostiale du tronc commun de la coronaire gauche 20 ans après une irradiation médiastinale.

A 43-year-old woman with no risk factors received mediastinal radiotherapy of 35 Grays at the age of 23 years for Hodgkin's disease, followed by cure of the neoplastic disease. Twenty years later, following a threatened infarction syndrome, coronary angiography revealed ostial stenosis of the left coronary trunk. The course was rapidly unfavourable immediately following the examination.

[Postoperative transparietal Doppler ultrasonographic study of the internal mammary artery graft flow with respect to quality of the underlying myocardium]. / Etude en écho-doppler transpariétal postopératoire du flux du greffon mammaire interne en fonction de la qualité du myocarde sous-jacent.

The authors studied flow in the internal mammary artery by Doppler ultrasonography after bypass surgery of the left anterior descending artery to determine the correlation between the flow pattern and the quality of the distal run off. A pulsed Doppler was used to record flow from the right and left internal mammary arteries in the first, second and third intercostal spaces and the supraclavicular fossa. Only the best quality recordings with the highest amplitudes were retained for analysis. Forty-nine patients (average age 61 +/- 10 years), 43 men and 6 women, were included and were examined between the 10th and 15th postoperative days. All had stenosis of the left anterior descending on coronary angiography: three subgroups were identified ad the time of evaluation: (I) revascularisation of an infarcted zone with important angiographic and echographic sequellae. (II) revascularised zones with slight wall motion abnormalities. (IIIa) revascularisation of myocardium with no abnormality (including a subgroup of 5 patients (IIIb) characterised by a postoperative low output state and echocardiographic changes not present before surgery). Significant changes were observed in the flow patterns of the different groups. (I) an exclusively systolic flow (diastolic velocity time integral = 2.85 cm), (II) systolodiastolic flow (diastolic velocity time interval = 9 cm) similar to that in group IIIb, and IIIa predominantly diastolic flow (diastolic velocity time integral = 15.2 cm). The amplitude of diastolic flow in the mammary artery graft was therefore related to previous ischaemia of the revascularised myocardium; detection of stenosis by Doppler ultrasonography should therefore take into account the previous history of the patient.

[Efficacy and tolerability of trandolapril in overweight hypertensive patients]. / Efficacité et tolérance du trandolapril chez l'hypertendu en surpoids.

An open multicentre study, performed in 340 overweight (body mass index: BMI > or = 25), hypertensive (95 mmHg < or = DBP < 115 mmHg) patients, evaluated the clinical and metabolic safety of trandolapril and confirmed its antihypertensive activity. After a two-week washout period, the patients received trandolapril 2 mg as a single morning dose for 12 weeks. Doubling of the dosage was authorized after the first four weeks when the DBP remained higher than 90 mmHg with a fall in DBP < 10 mmHg. Of the 287 patients who completed the study, 15.1% had to receive a double dose of trndolapril during the second treatment period. After four weeks of treatment, SBP was decreased by 18.6 mmHg, DBP was decreased by 13.4 mmHg and 63.1% of patients were controlled. After three months of treatment, SBP was decreased by 23.3 mmHg, DBP was decreased by 16.8 mmHg and 84.7% of patients were controlled. Subgroup analysis, according to the BMI (BMI > or = or < 30), showed that the fall in blood pressure was identical regardless of the BMI; the proportion of patients treated with a double dose of trandolapril was also independent of the BMI. A second subgroup analysis, according to the waist/hips ratio, did not reveal any difference according to the android or gynoid profile of excess weight. Twelve patients (3.9%) dropped out of the trial because of adverse events, 10 of which were attributable to treatment; 6.5% of patients reported an adverse effect attributable to treatment. Laboratory assays performed before and after three months of treatment demonstrated the very good metabolic safety profile of trandolapril, in view of the slight but significant reduction of total cholesterol, triglycerides and blood glucose. However, an average weight loss of one kilogram was reported. The global safety was considered to be good or excellent by the investigators in 94.8% of cases.

Acute limb ischemia and heparin-induced thrombocytopenia: the value of echocardiography in eliminating a cardiac source of arterial emboli.

We report an unusual thromboembolic event occurring during severe heparin-induced thrombocytopenia. A left intraventricular thrombus was diagnosed as the source of multiple arterial emboli, resulting in an initial cerebrovascular event and subsequent bilateral acute lower extremity ischemia requiring emergency surgery. No underlying heart disease was detected. Pathologic examination of the embolectomy specimen revealed fibrin platelet aggregates with rare white and red blood cells, consistent with a "white thrombus." We conclude that routine monitoring of platelet count should be performed in all patients receiving heparin to identify promptly individuals who have heparin-induced thrombocytopenia, and when thromboembolic complications occur in this setting, echocardiography is indicated to identify possible intracardiac sources for emboli, even in patients with previously known structurally intact hearts.

Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption.

BACKGROUND: Traumatic disruption of the aorta (TDA) is a life-threatening injury that requires rapid diagnosis and treatment. Emergency aortography, which is the current standard diagnostic imaging modality, is invasive, time-consuming, and difficult to perform in hemodynamically unstable patients with multiple trauma. We performed transesophageal echocardiography (TEE) in patients with suspected TDA to determine the diagnostic accuracy and impact on patient management of this alternative, portable imaging modality. METHODS AND RESULTS: Thirty-two consecutive trauma patients (mean age, 40 +/- 16 years) with suspected TDA (violent deceleration accident and mediastinum > 8 cm on admission chest x-ray) prospectively underwent a TEE examination in the emergency room. Findings during TEE were compared with those encountered during aortography, surgery, or necropsy. Two subsets of traumatic aortic injuries with distinct echocardiographic signs were observed: (1) subadventitial TDA (n = 10) and (2) traumatic intimal tears (n = 3). Eighteen patients had normal TEE confirmed by aortography. One 2-mm medial tear was missed by TEE (necropsy). The sensitivity and specificity of TEE for the diagnosis of subadventitial TDA were 91% and 100%, respectively. Patients with subadventitial TDA were taken to surgery immediately, whereas patients with intimal aortic tears were treated conservatively. Eighteen patients (mean age, 57 +/- 15 years) with confirmed acute aortic dissection involving the aortic isthmus were also included to establish the echocardiographic differential diagnostic criteria between this entity and TDA. CONCLUSIONS: TEE should be considered the first-line imaging modality for the evaluation of trauma patients with suspected injuries of the thoracic aorta because of its portability, safety, diagnostic accuracy, and potential impact on patient management.

[Total permanent auricular paralysis. Review of the literature apropos of 109 cases]. / La paralysie auriculaire permanente totale. Revue de la littérature à propos de 109 cas.

Analysis of 109 well documented cases of permanent total atrial paralysis reported in the literature illustrated the features of this arrhythmia which is a well defined entity consisting of suppression of all electrical and mechanical activity of both atria lasting for more than 6 months. Standard electrocardiogram reveals junctional bradycardia of about 40 bpm without any visible P waves and narrow supraventricular QRS complexes in 80% of cases. This diagnosis can only be confirmed by meticulous bipolar endocavitary recordings exploring all atrial walls without recording an auriculogram and by right intra-atrial and coronary sinus stimulation which proves to be ineffective. This disease has a male predominance in two-thirds of cases and a familial nature in 18% of cases. Seventy one per cent of affected subjects are under the age of 50 years. In 33% of cases, it is associated with Emery-Dreifuss muscular dystrophy, in which it constitutes a specific sign allowing this dystrophy to be differentiated from all other forms, especially facio-scapulo-humeral myopathy, and in 30% of cases, it is associated with a degenerative disease such as diabetes, amyloidosis or primary cardiomyopathy. Idiopathic dilatation of the right atrium is revealed in 15% of cases. The arrhythmia is responsible for syncope or faintness in 31% of cases, cerebral vascular accidents in 21% of cases and heart failure in 35% of cases. Cardiac activation is dependent on a junctional escape rhythm. The mechanism of the lesion responsible is atrial fibrosis which may extend to the sinoatrial node. The treatment of choice consists of implantation of a VVI or VVIR mode cardiac pacemaker in combination with anticoagulant therapy.

[Prognostic effect of diverse surgical parameters in significant stenoses of the left coronary trunk. Retrospective study of 185 cases]. / Influence pronostique des divers paramètres opératoires dans les sténoses significatives du tronc coronaire gauche. Etude rétrospective de 185 cas.

A retrospective study of 185 cases of left main coronary artery stenosis operated between 1980-01-01 and 1991-06-15 at the Limoges University Hospital Center was performed. The influence of operative procedures: cardiopulmonary bypass and aortic cross clamping times, type and number of coronary grafts, time between coronary surgery and coronary angiography, on early (before the 30th days after surgery) and late postoperative vital prognosis was studied. This study confirms in our study the poor early postoperative prognosis of: 1) cardiopulmonary bypass time over 140 min; 2) coronary bypasses in an emergency context (surgery less than 24 h after coronary angiography); 3) incomplete coronary revascularization. The nature of grafts and the aortic cross clamping time have no influence. The actuarial survival studies confirm the poor long-term postoperative prognosis of incomplete coronary revascularization; the other surgical procedures have no influence.

Transesophageal echocardiography for the diagnosis and management of nonobstructive thrombosis of mechanical mitral valve prosthesis.

BACKGROUND: Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography. METHODS AND RESULTS: One hundred fourteen consecutive patients with mechanical mitral valve prosthesis were investigated by both transthoracic echocardiography and transesophageal echocardiography. These examinations were performed for recent systemic emboli (15 patients), fever of unknown etiology (11 patients), routine postoperative evaluation (56 patients), and other reasons (32 patients). Based on transthoracic echo diagnosis, all prostheses were considered normal. Yet, in 20 patients transesophageal echocardiography revealed the presence of a 2- to 15-mm-long mobile thrombus localized on the atrial surface of the prosthesis. When compared with the remaining 94 patients with no visible thrombi, there was no significant difference between the two groups in terms of incidence of atrial fibrillation (65% versus 52%), left atrial size (48 +/- 9 versus 51 +/- 13 mm), left ventricular end-diastolic diameter (49 +/- 10 versus 51 +/- 13 mm) and fractional shortening (28 +/- 9% versus 31 +/- 10%), presence of spontaneous contrast to the left atrium (40% versus 41%), transprosthetic mean pressure gradient (4.0 +/- 1.4 versus 3.9 +/- 1.5 mm Hg), or the type of prosthesis used. After we discovered a nonobstructive thrombosis, patients were treated with heparin (n = 9) or oral anticoagulation (n = 11). The presence of a localized thrombus was confirmed in 3 patients who were operated on. In the present study, evolution appeared to depend on thrombus size: of 14 patients exhibiting a small (< 5 mm) thrombus, 10 had an uneventful course, whereas 5 of 6 patients with a large (> or = 5 mm) thrombus developed complications or died. CONCLUSIONS: Transesophageal echocardiography appears to be a reliable method to diagnose thrombi on a mechanical mitral valve prosthesis, even when transthoracic Doppler echocardiographic parameters appear to be normal. Transesophageal echo assessment of thrombus size may be helpful in deciding whether a patient with mitral prosthesis should be treated by anticoagulation, thrombolysis, or valve rereplacement.