[Rotablator and endoprosthesis on the left main coronary trunk]. / Rotablator et endoprothèse sur tronc commun de la coronaire gauche.

A 78 year old woman with unstable angina due to significant stenosis of the left main coronary artery and occlusion of the right coronary artery was treated medically for 29 months because of a surgical contraindication. Resistance to drug therapy led to referral for complex angioplasty of the left main, left anterior descending and left circumflex arteries, successively by rotablator and balloon angioplasty. An immediate elastic recoil on the left main coronary artery led to implantation of a Palma-Schatz stent. There were no complications and the patient is asymptomatic twenty months later.

[Thromboembolic disease in patients aged 80 and over. Diagnostic and therapeutic strategies]. / La maladie thromboembolique chez la personne âgée de 80 ans et plus. Stratégies diagnostiques et thérpeutiques.

The aim of this retrospective study of 50 deep vein thromboses (DVT) of the lower limbs in patients aged 80 and over (35 women, including 2 with bilateral DVT and 13 men), mean age 83.37 +/- 2.72, hospitalised in a department of cardiology, was to assess the diagnostic value of ultrasound investigations, clinical parameters and results of treatment of thrombo-embolic disease in this age group. High DVT were found in 76 per cent of cases and pulmonary embolism occurred in 52.1 per cent of cases, its incidence increasing with age. One third of DVT were asymptomatic and presented as pulmonary embolism, the predominant clinical feature being edema in the absence of other signs. The existence of atrial fibrillation was associated in 90 per cent of cases with a pulmonary embolism. Venous Echo-Doppler is also the key investigation in the diagnosis of thrombo-embolic disease. Cardiac Echo-Doppler seems particularly useful in the diagnosis of pulmonary embolism when more than 40 per cent of the vascular bed is cut off. Thrombolytic treatment remains possible after the age of 80 in life-threatening situations. Overall hospital mortality remains high (10.4 per cent) and appears to be due chiefly to the onset of a pulmonary embolism which is not thrombolyzed since considered insufficiently serious or occurring in a situation in which fibrinolysis is theoretically contra-indicated.

[Relations between antihypertensive and vascular effects of nitrendipine]. / Relations entre les effets antihypertenseurs et vasculaires de la nitrendipine.

We have realized an unicentric prospective study to assess the effects of Nitrendipine on carotid circulation and arterial blood pressure (BP) in essential, permanent, uncomplicated arterial hypertension. This randomized, double blind versus placebo trial concerned 21 mild to moderate hypertensive patients (pts) (WHO advices) aged from 35 to 65 years. After a 15 days washout, the pts were randomized in two groups: 11 pts received a 20 mg Nitrendipine tablet once a day and 10 pts received a placebo. BP control and ultrasonic carotid flowmetry were performed at J0 and J30. At J30, BP was normalized for 55% of pts under NT (versus 30% for placebo). This result correspond to a very significative decrease for systolic and diastolic BP and differential BP (Dif BP) without reflex tachycardia, under Nitrendipine, opposite to placebo. Ultrasonic carotid flowmetry variations are not significative excepting common carotid vasodilation under Nitrendipine. Under Nitrendipine, at J30, 5 pts show a decrease of a least 15% of the cerebral vascular resistances (responding patients); and 6 pts do not show any significative decrease of cerebral vascular resistances. For the responding pts, arteriolar vasodilation is then correlated to the decrease of BP and Dif BP, to the increase of carotid blood flow and to the arterial vasodilation; while there is no significative decrease of BP for non responding pts. It suggests an improvement of arterial compliance by a direct action on the arterial wall. Furthermore, inspite of a drop in diastolic parietal tension, there is not any group showing reflex tachycardia. Thus, antihypertensive efficacy of Nitrendipine seem to be principally subordinated to the improvement of arterial compliance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pheochromocytoma and hyperthyroidism caused by amiodarone]. / Phéochromocytome et hyperthyroïdie à l'amiodarone.

The authors report, in a 66 y. old patient, a case of pheochromocytoma, interesting in that its initial clinical picture is one of amiodarone-induced hyperthyroidism with orthostatic hypotension, and a persisting severe weight loss in spite of the improvement of the thyroid work-up is the indication of an adrenal tumor discovered on tomodensitometry. The accidental combination of these two endocrine diseases delays the already unusual manifestation of this pheochromocytoma and emphasizes the role of radiographic (tomodensitometry) and/or isotopic (MIBG) imaging in the "discovery" of these tumors.

[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)

[Atypical echocardiographic aspects of cardiac amylosis]. / Aspects échographiques atypiques de l'amylose cardiaque.

Echographic abnormalities of cardiac amylosis are now well known and quite useful to the diagnosis. Forms that are morphologically atypical are rare. From three observations (2 hypertrophic, asymmetrical and obstructive forms, and 1 hypertrophic and dilated form) and a review from the literature, we study the nosological, diagnostic and therapeutic problems presented by these atypical echographic of cardiac amylosis.

[Ultrasonic detection of arteriosclerosis of the main arterial trunks in the coronary patient]. / Athérosclérose des gros troncs artériels chez le coronarien, dépistage ultrasonore.

Ultrasonic investigations of the peripheral vessels (continuous Doppler with spectral analysis, echotomography) were performed to evaluate atherosclerosis of the main arteries (abdominal aorta, cervical arteries, lower limb arteries) in 50 coronary patients and 40 control subjects. In the main, our results support those of previously published series (epidemiological and autopsy studies): Atherosclerosis of the main arterial vessels is significantly more common (p less than 0.01) in coronary patients than in control subjects: carotid lesions: 70% (including 10% with severe stenosis) compared to 32% (no severe stenosis); aortic lesions: 50% (including 20% with severe stenosis) compared to 17.5% (7.5% severe stenosis); lower limb arteries: 58% (including 16% severe stenosis) compared to 12.5% (no severe stenosis). The difference of incidences of associations of atherosclerosed vessels between the two groups was significant (p less than 0.01): no peripheral vascular disease was detected in 57.5% of controls compared to only 12% of coronary patients; more than one territory diseased in 15% of controls compared to 58% of coronary patients. The severity of these lesions correlated with the presence of the three major cardiovascular risk factors which were studied (hypertension, smoking, hypercholesterolaemia) and was significantly higher (p less than 0.01) in coronary patients (38% had more than one major risk factor and only 10% had none) than in controls (47% had no risk factors and 6% had more than one). In addition, the preferential sites of atherosclerosis were also confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Auricular fibrillation in the elderly. Indicators of risk and cerebral prognosis]. / La fibrillation auriculaire chez la personne agée. Indicateurs de risque et pronostic cérébral.

Cardiovascular anomalies contributing to development of atrial fibrillation (AF) and subsequent cerebral repercussion have been studied by analysis of clinical, electrocardiographic and anatomicopathological data for 131 elderly (85.16 +/- 6.7 years) medium- and long-term hospital patients. AF was seen in 22.14% of cases and seems more frequent in the ninth decade than in the eight. Predisposing factors were coronary alterations of repolarization (p less than 0.001), myocardial hypertrophy (less than 0.01), hypertension with cardiac repercussions (p less than 0.01), intraventricular conduction disorders, left anterior hemiblock excepted (p less than 0.05) and mitral valvulopathy. AF developed in 12% of cases without apparent cardiopathy. The risk of cerebral infarct was marginally greater in the presence of AF than in its absence; the risk was clear for paroxysmal forms and nil when AF developed in a healthy heart. In contrast, intellectual deterioration and cerebral hypotrophy were significantly more marked (p less than 0.01) in patients presenting AF. This affirmation is evidence for long-term hemodynamic repercussions of arrhythmia affecting cerebral blood flow and constitutes an argument for re-establishment of sinusal rhythm.

[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.