Unusual presentation of a left ventricular aneurysm.

We report on a case of left ventricular aneurysm in a 42-year-old woman presenting with atypical chest pains. The resting electrocardiogram showed abnormal Q and T negative waves in leads II, III, and aVF. Transthoracic echocardiography revealed an aneurysm on the posterior wall of the left ventricle. Thallium myocardial tomoscintigraphy confirmed the presence of a persistent defect with uneven uptake in the posterior wall, and coronary arteriography showed perfectly normal coronary arteries. A left ventricular aneurysm associated with normal coronary arteries and transient ischemia was diagnosed following a comparison with one of the patient's old electrocardiograms.

[Clinical value of measuring systolic arterial blood pressure post-exercise for evaluation and diagnosis of coronary disease: comparative study between women and men]. / Intérêt clinique de la mesure de la pression artérielle systolique dans le post-effort pour l'évaluation et le diagnostic de la maladie coronarienne: étude comparative entre femmes et hommes.

It has been demonstrated that the ratio of the systolic blood pressure post-exercise to that at peak exercise (rSBP) is a criterion for diagnosis and severity of coronary artery disease (CAD) in men. No such demonstration has been attempted in women. We have compared SBP to classical signs of ischemia, such as ST segment depression and angina pectoris, in a group of 788 ambulatory patients of whom 357 were women. All underwent a bicycle ergometric test and a coronary angiogram. The prevalence of CAD at angiography was the same for both genders (women 43.5% and men 47%) with no significant difference in the number of vessels diseased. In patients with CAD, the rSBP was significantly more elevated than in others, at 1 minute (p < 0.01) and even more so at 3 minutes (p < 0.001) post-exercise, with no gender difference. The most discriminating value of rSBP at 3 minutes post-exercise for diagnosis of CAD was situated at 0.91 for sensitivity and specificity (receiver operating characteristic curve analysis). In the whole group sensitivity of rSBP is lower, while the specificity is greater than classical criteria of ischemia. The sensitivity of rSBP is poor for the diagnosis of single vessel disease, but of equal value compared to ST segment depression in the presence of multivessel disease, with no gender difference. The specificity of rSBP is higher than ST segment depression in women (p < 0.001) compared to men (p < 0.05). rSBP has a positive correlation with the number of coronary vessels diseased but not with the extent of ST segment depression. Our study demonstrates that rSBP at 3 minutes post-exercise is a less good diagnostic sign than the classical criteria of myocardial ischemia. However, rSBP has good specificity, particularly in women, thus reducing false positive tests related to ST segment depression. rSBP is also a marker of the severity of coronary artery disease.

Effect of low left ventricular ejection fractions on the outcome of primary coronary by-pass grafting in end-stage coronary artery disease.

Advanced ischemic heart disease (HID) with very low left ventricular ejection fraction (LVEF), pulmonary hypertension (PHT) with or/without left ventricular aneurysm (LVA) are criteria for defining end-stage coronary artery disease (ESCAD). Coronary artery by-pass grafting is often denied to these patients. Between January 1990 and December 1993, 91 patients with ESCAD, significant 2 or 3-vessel disease (stenosis > or = 70%) and LVEF < or = 25% underwent primary CABG at our institutions. The mean age was 62.5 +/- 8.0 years (41-81), 89% were men. Eighty-one patients were in preoperative NYHA (New York Heart Association) functional class 3 and 4. Mean LVEF was 21.3 +/- 3.8% (10-25). Mitral regurgitation (MR) was present in 39/91 (43%). The systolic pulmonary artery pressure (PAP) was 33.2 +/- 17.1 mmHg (11-75) and the wedge pressure was 19.0 +/- 10.8 mmHg (5-47). Twenty-two patients had significant PHT with a systolic PAP > or = 40 mmHg. The overall perioperative mortality was 14.3% (13/91). Low postoperative cardiac output occurred in 33 patients, requiring intraaortic balloon support in 13. Gastrointestinal complications occurred in 6 patients and neurological events in one. Fifteen patients had additional left ventricular aneurysm repair. There was a good correlation between LVEF and PAP (r = 0.782). Surprisingly, in a subset of patients with preoperative PHT and LVEF < or = 25% the mortality rate was only 4.6% (1/22). Other perioperative complications did not differ.(ABSTRACT TRUNCATED AT 250 WORDS)

[Change in indications for coronary angiography in a decade]. / Changement des indications à la coronarographie au cours d'une décennie.

To characterize the changes in indications for coronary angiography we compared indications and therapeutic conclusions of cardiac catheterization, including coronary angiography, in 100 consecutive patients in 1975 and 100 consecutive patients in 1985. The baseline characteristics of the patients in the two groups were similar, except for age (50 +/- 10 vs 56 +/- 9 years, p less than 0.0001) and prior angioplasty (0 vs 12, p less than 0.0001). The main indications for coronary angiography in the two groups were (1975 vs 1985) chest pain in 67 vs 62 (n.s.), myocardial infarction in 10 vs 17 (n.s.), prior coronary surgery in 3 vs 0 (n.s.), major arrhythmias in 1 vs 1 (n.s.), and incidental (coronary pathology not the primary issue) in 19 vs 8 (p less than 0.05). We further analyzed each of the main indications in the two groups. Chest pain: angina ruled out in 21% vs 26% (n.s.), stable angina 64% vs 61% (n.s.), unstable angina 15% vs 13% (n.s.), positive non-invasive tests 39% vs 44% (n.s.). Myocardial infarction: acute intervention 0 vs 12% (n.s.), angina after infarction 20% vs 47% (n.s.), positive non-invasive tests after myocardial infarction 20% vs 41% (n.s.). Incidental: valvular heart disease 57% vs 63% (n.s.), cardiomyopathy 26% vs 13% (n.s.), congenital heart disease 11% vs 0 (n.s.), aortic dissection 5% vs 25% (n.s.), other 5% vs 0 (n.s.). Overall, clinical suspicion of coronary artery disease was confirmed and documented in 80% (65/81) vs 77% (61/79) of patients (n.s.), and normal coronary arteries were found in 20% (16/81) vs 23% (18/79) of patients respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Angiographic study of the dynamics of the interventricular septum]. / Etude angiographique de la dynamique du septum interventriculaire.

The interventricular septum was studied by biventricular angiography in 52 patients divided into 4 groups: the first group consisted of 14 normal subjects; the second of 10 patients with hypertension (9 cases) or aortic stenosis (1 case); the third, of 19 patients with echocardiographic asymmetric septal hypertrophy, and the fourth, of 9 cases of cardiomyopathy with dilatation. The following parameters were measured: septal thickness at 4 different points and mean septal thickness, the height (long axis) and surface of the septum in diastole and systole. The percentage variation was calculated. There were no significant differences between Group I and II; there was a significant difference (p less than 0,01) in the variations of septal thickness of the upper segments between Group I and III. This difference remained significant (p less than 0,05) for the variations of mean thickness between Group I (-38%) and Group III (-18%). There was also a significant difference (p less than 0,05) in the variation of height between Group I (23%) and Group IV (9%). None of the variations of septal surface reached the threshold of statistical significance between the four groups. Biventricular angiography can therefore demonstrate certain abnormalities of septal motion. In asymmetric septal hypertrophy, the variations in thickness are significantly less pronounced than in normal subjects but the motion in the longitudinal axis does not differ significantly. In cardiomyopathy with dilatation, however, the variation in septal height is the most affected parameter.

[Value of echocardiography in the diagnosis of Uhl's disease. Apropos of a case in an adult]. / Intérêt de l'échocardiographie dans le diagnostic de la maladie de Uhl. A propos d'une observation chex l'adulte.

Uhl's anomaly, or paper thin right ventricle is a rare congenital malformation which may present with variable degrees of hypoplasia. The most severe forms are encountered in infants and children, but a less serious form occurs in adolescents and adults which, clinically. There are a number of echocardiographic features common to both diseases but paper-thin right ventricle may be distinguished by the finding of premature opening of the pulmonary value. The increased atrial contraction in these patients with right ventricles of reduced compliance is directly transmitted to the pulmonary artery, leading to end diastolic opening of the pulmonary value before tricuspid closure. The case presented underlines the value of M mode echocardiography in the diagnosis of Uhl's anomaly and in the differential diagnosis with Ebstein's anomaly.

[Isotope angiocardiography: amelioration of the measurement of ejection fraction by a new treatment of the image]. / Angiocardiographie isotopique: amélioration de la mesure de la fraction d'éjection par un nouveau traitement d'image.

Some of the limitations affecting radioisotopic images are their insufficient resolution, structure boundaries and accurate subtraction of background noise. In order to improve the signal-to-noise ratio the images of the recorded heart cycles are treated by the Karhunen-Loeve transformation. Edge detection is based on compression of the image to a bitmap at a chosen level and following of all bits set to one by a pointer. The outlines of the structures as determined by edge tracking are used to define the regions of interest within the enhanced images. Background subtraction applies the principle of interpolative background subtraction by computing an individual background for each point in an irregular region of interest. The resultant images are used to calculate an index of cardiac efficiency which shows high correlation (r = 0.92) with the ejection fraction of contrast biplane left ventricular angiography.

The late post-operative patency rate of aorto-coronary venous grafts.

Long-term aorto-coronary venous graft patency has been examined in a consecutive series of 47 patients (average: 1.6 graft per patient) after a mean follow-up period of 5 years and 9 months (44-108 months) post surgery. Overall patency rate was 71% (52/73 grafts), with the best results for LAD grafts 85% (27/32). Seventy-seven percent of the patients experienced lasting relief from angina. Significant improvement of LV ejection fraction was observed in cases with patent grafts.

[Interventricular septum. Angiographic and echocardiographic correlations]. / Septum interventriculaire. Corrélations angiographiques et échocardiographiques.

The diastolic thickness of the interventricular septum was measured by echocardiography and by biventricular angiography in 48 patients (40 male, 8 female) with age ranging between 15 and 67 years (average 44.4 years). These patients were classified in four groups according to clinical and paraclinical parameters:--normal subjects (29 cases),--patients with concentric hypertrophy (5 cases),--patients with asymmetrical septal hypertrophy without obstruction (4 cases),--patients with hypertrophic cardiomyopathy with obstruction under basal conditions or under stress (10 cases). Biventricular cineangiography was performed in 70 degrees left anterior oblique projection after measuring the intracavitary pressures. Analysis was performed by projecting the film and reproducing one or several diastolic frames on paper. Septal thickness was measured at the two levels suggested by Redwood. The septum was then divided into 5 parts and the thickness measured at the corresponding 4 levels. The values obtained were then corrected for magnification artefact. Qualitative comparison of the results obtained by echocardiography and angiocardiography showed a good correlation in 35 cases (73%) and less significant correlations in the other 13 cases (27%). The poorest correlations were observed in the groups of patients with concentric or asymmetrical hypertrophy without obstruction. Of these 13 cases, angiography confirmed the clinical diagnosis in 6 cases. In the remaining 2 cases, echocardiography and angiocardiography gave divergent diagnoses which also differed from the clinical diagnosis. The quantitative correlations between the echocardiographical and angiocardiographic measurements of diastolic septal thickness were quite satisfactory in most patients. The correlation improved when the echocardiographical measurement was compared to an average of the 4 angiographical measurements; (R = 0,74; p < 0.001). The correlation was poorer in groups 2 and 3 in patients with concentric or asymmetrical hypertrophy without obstruction. The disadvantages and limitations of these two methods are discussed. Possible ambiguity in the identification of segments of the septum measured by the two methods may be a significant factor especially in cases of asymmetrical hypertrophy.

[Permeability of venous aortocoronary bypass 5 years later]. / Perméabilité à 5 ans des pontages veineux aorto-coronariens.

47 consecutive patients who had undergone aorto-coronary venous bypass surgery (mean: 1.6 graft per patient) have been investigated after a mean follow-up period of 5 years and 9 months (range: 44-108 months). 52 grafts out of 73 were found to be patent (71 p. 100), the best patency rate being shown by grafts on the LAD artery (27/32 = 85 p. 100). Long-term graft patency may be associated with an improved left ventricular ejection fraction; 77 p. 100 of the total patients experienced a lasting clinical benefit from the operation.

[Prognosis for coronary patients with low ejection fraction. Comparison between a medically and a surgically treated group]. / Pronostic des coronariens ayant une fraction d'éjection basse. Etude comparée d'un groupe traité médicalement et d'un groupe opéré.

Two groups of coronary patients whose ejection fraction was depressed (less than or equal to 0.30) were studied. Twelve patients received drug treatment only and 25 others underwent surgery. Life expectancy appears to be slightly improved in the surgical group, but the differences are not statistically significant. Since operative mortality is relatively low (8%) and clinical improvement following surgery may be impressive, a revascularization procedure should be considered even in patients with markedly impaired ventricular function.

Congenital arteriovenous fistula of the internal mammary vessels: report of a case and review of the literature.

The case of a congenital arteriovenous fistula of the internal mammary vessels in a 41 year-old woman has been reported, and the pertinent literature briefly reviewed. These rare lesions may become apparent only relatively late in life. The accompanyiny signs are often misleading. In view of the uncertain long-term outlook, surgery seems indicated.

[Stenosis of the left coronary trunk. Apropos of fifteen cases]. / Les sténoses du tronc coronaire gauche. A propos de quinze cas

Stenosis of the left main trunk was revealed by selective coronary angiography in 15 patients among the 567 who were investigated (2.6%). No case of total occlusion was observed. There was no fatality due to the procedure. As a rule other coronary vessels also show atheromatous lesions. Five patients were not operated: 3 died (60%) after a mean survival period of 14 months following angiography. Among the 10 others who underwent surgery there was no operative mortality, but 2 patients died in the postoperative period (20%). The 8 survivors have been followed for a period ranging from 8 to 61 months (mean: 36 months). All are still alive and much improved clinically. Once the diagnosis of left main trunk stenosis has been established, early surgery should be considered.

[Percutaneous selective coronarography. Apropos of 600 cases]. / La coronarographie sélective percutanée. A propos de 600 examens

600 selective coronary angiographies were performed in 559 patients, using Judkins preformed transfemoral catheters. One fatality was deplored (mortality: 0,17 p. 100). 15 cardiac complications were observed 2,5 p. 100), 10 of which were severe but rapidly corrected arrhythmias. Among these 559 patients 495 were clinically cases suffering from probable or certain coronary heart disease. 88 p. 100 of this group were men. Selective coronary angiography revealed stenosis with decrease of at least 50 p. 100 of the lumen in over 80 p. 100 of the cases. The anterior descending was the most frequent site of stenosis. In the majority of cases, and especially in men, two or several vessels were diseased. There is some relationship between the development of collateral circulation and the extension of coronary disease. In one third of the cases, ventricular function, assessed by measurement of the ejection fraction was impaired.

Selective percutaneous coronary arteriography: an experience with 600 procedures.

Six hundred selective percutaneous coronary angiographies have been performed, using the Judkins technique. The procedure was well tolerated even by critically ill patients. Considering the low risk (mortality: 1.7%), the relatively infrequent complications (2.7%) and the value of the information obtained, selective coronary arteriography is a prerequisite to any meaningful surgery.