[Idiopathic mitral valve prolapse and prolapse leakage. Study using Doppler ultrasound in 51 cases]. / Prolapsus valvulaire mitral idiopathique et fuites valvulaires. Etude par écho Doppler de 51 cas.

This study concerns 51 cases of mitral valve prolapse demonstrated on bidimensional 4 cavities sonography according to Gilbert's criteria and aims to determine the frequency of the associated valvular involvement, anatomically with sonography and functionally with the Doppler test. Sonography demonstrates a tricuspid valve prolapse in 79 p. cent of the cases and an aortic valve prolapse in 10 p. cent. The Doppler test demonstrates a tricuspid leakage in 52 p. cent of the cases, a pulmonary leakage in 62 p. cent, and an aortic leakage in 18 p. cent. The myxoid degeneration found in 60 p. cent of the cases is a major factor in the occurrence of complications, especially progressive cardiac insufficiency (A). The myxoid degeneration defines therefore the "isolated prolapse disease" as opposed to "the prolapse without myxoid degeneration" which is a pure sonographic entity and probably a variation of the normal (A). This cardiac insufficiency occurs late during the 6th or 7th decade and is due to mechanical factors: prolapse, chords rupture and annular dilatation.

[Diagnosis of aortic stenoses by Doppler sonography]. / Le diagnostic des sténoses aortiques par Doppler.

Doppler sonography permits to diagnose the gravity of valvular aortic stenosis if absolute conditions of reliability of the method are respected. The Doppler examination must be performed by a physician particularly familiar with this technique because it is a difficult examination. Systematic trial of the 5 possible approaches of the aortic orifice must be required: apical, left and right parasternal, substernal and sub-xyphoid approaches. Only velocity curves with a well defined contour must be retained and the concordance of the maximal velocities obtained by apical and parasternal approaches is in favor of a good alignment of the ultrasound beam on the aortic flow. It must be remembered that any sub-aortic obstacle or severe aortic insufficiency simulates an aortic stenosis on a continuous Doppler and that it is necessary to resort to the pulsated Doppler to rectify the diagnosis: acceleration of the flow occurs therefore in the flush chamber of the left ventricle and not at the level of the sigmoid orifice. We will remember that the Doppler does not provide the peak to peak gradient seen in hemodynamics but the maximal instant gradient which is always higher than the first one, and more especially as the aortic stenosis is more moderate. The best criteria of gravity of an aortic stenosis remain the mean gradient and the valvular area: the mean gradient is easily deduced from the quadratic transformation of the Doppler velocity curve and from a simple planimetry. The valvular area is obtained by applying the continuity equation which permits to get rid nicely of the cardiac output but still requires more validation before becoming part of the routine.

Screening of medicinal plants of Rwanda for acaricidal activity.

A series of 108 samples from 42 medicinal plants of Rwanda have been screened for acaricidal activity against the female tick Rhipicephalus appendiculatus. Two plants, Solanum dasyphyllum (fruits) and Neorautanenia mitis (roots) showed apparent acaricidal activity in the petroleum ether fraction.

[Myocardial fibroma. Apropos of a case followed for 11 years]. / Fibromes myocardiques. A propos d'un cas suivi pendant 11 ans.

A case of myocardial fibroma of the left ventricle is described in a young girl. The association of recurrent ventricular tachycardia and radiological deformation of the cardiac silhouette suggested the diagnosis and it was confirmed by myocardial scintigraphy, echocardiography and coronary angiography. At surgery, the tumour was too extensive to be removed. After 11 years follow-up, control of the arrhythmias is satisfactory and there has been no apparent increase in the tumour size. A review of 116 cases in the literature confirms the poor prognosis of myocardial fibroma. The diagnosis was made at autopsy in 60 cases. The 56 remaining patients were operated. Total resection was possible in 37 cases and partial resection in 4 cases. The tumour could not be removed in 15 cases. Overall operative mortality was 35 p. 100 but the prognosis thereafter was good.

[Our experience of the detection of latent pericardial effusions in the 3d trimester of pregnancy]. / Notre expérience du dépistage des épanchements péricardiques latents au troisième trimestre de la grossesse.

Following the paper published by Haiat, in which he reported the ultrasonographic detection of latent pericardial effusions in the third trimester of pregnancy, the authors conducted a study of 129 cases: 99 hospitalized patients (series I) and 30 patients seen in the consulting rooms (series II). Pericardial effusions were detected in 15% of cases in series I and in 20% of cases in series II, despite a more sophisticated apparatus. In general, these effusions were quite small. Hypertension of pregnancy was an aetiological factor observed in a significant number of cases. The presence of such effusions does not require aspiration, even when they are large, because of their perfect functional tolerance.

[Pulsed Doppler in the diagnosis of tricuspid insufficiency]. / Apport du Doppler pulsé au diagnostic d'insuffisance tricuspidienne.

Forty-eight patients underwent M-Mode, 2D and pulsed Doppler echocardiography with systematic apical and subcostal examination of the mitral and tricuspid orifices to determine the value of pulsed Doppler echo in the detection of tricuspid regurgitation. The fourty-eight patients, aged 12 to 69 years, were divided into 2 groups: Group I: 27 patients referred for cardiac catheterisation usually with a view to surgery. The majority of patients had rheumatic valvular, congenital heart disease or cardiomyopathies. All of these patients had phonocardiography, right and left heart catheterisation, right ventricular angiography and measurement od cardiac output. Group II: 21 control patients with no auscultatory, radiological or electrocardiographic changes. This group was studied to determine the specificity of pulsed Doppler examination of the tricuspid valve and the patients only underwent echocardiography. Selective right ventricular angiography was selected as the reference. The sensitivity, specificity and predictive value of pulsed Doppler echocardiography in the positive diagnosis of tricuspid regurgitation were determined. Its value in quantifying tricuspid regurgitation was also analysed. The sensitivity of pulsed Doppler was 93 p. 100 in this series: all but one case of angiographically proven tricuspid regurgitation were detected by the finding of unequivocal systolic turbulence in the right atrium. The specificity of pulsed Doppler was 91 p. 100. The positive predictive value of systolic turbulence in the right atrium was 81 p. 100. The only reliable criteria for quantifying the regurgitation were the intensity of the acoustic signal and the spatial extension of intraatrial turbulent flow: all patients with turbulent flow propagating as far as the superior wall of the right atrium or the inferior vena cava had angiographically severe tricuspid regurgitation. A comparison with other paraclinical methods of detecting tricuspid regurgitation showed that pulsed Doppler echocardiography is the most sensitive tool at the clinician's disposal for diagnosing this lesion: the sensitivity of auscultation and phonocardiography was 50 p. 100, jugular pulse tracings 54 p. 100, right heart catheterisation 50 p. 100, and pulsed Doppler echocardiography 93 p. 100. Pulsed Doppler echocardiography may even be superior to angiography which has, until now, been the method of reference for diagnosing tricuspid regurgitation.

[Value of calcium inhibitors in stable effort angina. Diltiazem versus nifedipine]. / Intérêt des inhibiteurs calciques dans l'angor d'effort stable. Diltiazem versus nifédipine.

Few studies have been devoted to the role of calcium blockers in stable angina of effort. For this reason, we undertook, a double-blind, randomized study with placebo, to compare the effects of diltiazem (D) and nifedipine (N) on the ergometric parameters of 20 patients with angina of effort and with mono- or multivessel disease. The study protocol extended over 3 weeks and included a reference stress test, 8 days of placebo followed by a repeat yesy, an then 15 days during which each patient received 180 mg of D and/or 30 mg of N in cross-over. A stress test was performed at the end of each week. The calcium blockers appeared to improve the effort tolerance, the duration of the ergometric test and the amplitude of the maximal ST segment depression. Diltiazem showed itself to be superior to nifedipine by the absence of side effects and by an improved cardiac performance on effort.

[Echocardiography in the diagnosis of pericardial effusion and tamponade]. / Contribution de l'échocardiographie au diagnostic des épanchements péricardiques et des tamponnades.

Fifty-seven patients who had presented pericardial effusions, compressive in ten cases, were subjected to M. mode echocardiography in order to identify specific signs of cardiac tamponade during major effusions. Certain criteria were of no diagnostic value: right and left ventricular diameter, mitral valve opening amplitude, and aortic diameter (p greater than 0.1). Apart from known hemodynamic and clinical signs, one must bear in mind two echographic signs that are specific for tamponade and disappear after drainage: protosystolic notching on the anterior wall of the right ventricle appearing 0.04 s after QRS, and a slope EF less than 50 mm/s.

[Chylopericardium, chylothorax and cystic lymphangioma. Review of the literature apropos of a case]. / Chylopéricarde, chylothorax et lymphangiome kystique. Revue de la littérature à propos d'un cas.

One case of chylopericardium associated with chylopneumothorax is reported. Published data make it clear that the pathogenesis of effusions of chyle is imperfectly known and still highly hypothetical. With the exception of tamponade, there are few pathognomonic and dramatic signs. TM and cross-sectional echography is of paramount importance, since it provides a qualitative and quantitative diagnosis of effusion, the nature of which is determined by chemical analysis. Effusions of chyle may be idiopathic or may developed after oesophago-cardio-pulmonary surgery, or even after blockade of lymphatic vessels or as a result of increased lymphatic flow rate or pressure. Although the course of the disease is usually favourable, infectious or haemodynamic complications (e.g. tamponade or constriction) may aggravate the prognosis. Treatment is exclusively surgical and consists of partial pericardectomy, which is unquestioned. There is no consensus of opinion about simultaneous ligature of the thoracic duct.

[Echocardiography in the diagnosis of severe aortic valve stenosis in adults]. / Apport de l'échocardiographie au diagnostic des sténoses aortiques valvulaires sévères de l'adulte.

A series of 45 adults with severe valvular aortic stenosis underwent echocardiographic examination before surgery. The echocardiographic indices of the severity of the stenosis were reviewed: In M mode: aortic valve opening was only clearly defined and quantifiable in 22 out of 45 cases. In these 22 cases, the separation of the valves was variable in 9 cases; the stenosis was underestimated in 2 cases both of which were unsuspected bicuspid valves; the stenosis were overestimated in 1 case leading to an erroneous diagnosis. In 2D: aortic valve opening was easier to detect than in M mode; it was quantifiable in 16 out of 21 patients (80 p. 100). The subcostal view was particularly valuable in patients with chronic pulmonary disease or with barrel-shaped chests. The 2D examination however, suffers from the same limitations as M mode: variability in the values of aortic valve opening in a third of cases and a general tendency to overestimate the severity of the stenosis. In two cases an erroneous diagnosis of severe stenosis was made in cases of simple aortic sclerosis either because of the inability to visualise a mobile 3rd left anterior cusp in the long axis view or because of artefact due to paravalvular calcification. The most reliable index of severity was the thickness of the left ventricular posterior wall: this measurement was never less than 13 mm, with a mean value of 15,8 +/- 1,8 mm in the 43 patients in whom it was measured. The measurement was also of prognostic significance; paradoxical thinning of the posterior wall and septum was a poor prognostic sign which was associated with cardiac failure and passive dilatation of the left ventricle sometimes shortly preceding sudden death. In the absence of cardiac failure, a posterior wall thickness of less than 13 mm excludes surgical aortic stenosis.

[Echocardiography in pericardial effusion and tamponade (author's transl)]. / Apport de l'échocardiographie dans les épanchements péricardiques et les tamponnades. 57 observations.

The role of echocardiography in the diagnosis and quantitative assessment of pericardial effusion was demonstrated in 57 cases, 10 of which were confirmed by surgery. With this highly sensitive method all effusions equal or superior to 50 ml could be detected and their volume measured with accuracy. There were no false positive results. Two specific signs of tamponade came out very clearly: a decrease in EF slope, which was less than 50 mm/sec, and a notch in the anterior wall of the right ventricle which occurred 0.04 +/- 0.01 sec after QRS.

[Two-dimensional echocardiography and mitral valve involvement]. / Echographie bidimensionnelle et atteinte mitrale.

Two-dimensional echocardiography has been a decisive advance in the investigation of rheumatic valvular disease. In mitral stenosis, short axis views enable a quantitative evaluation of mitral surface area by planimetry. Long axis views contain additional important information on the state of the subvalvular apparatus and on the possible presence of left atrial thrombosis. The quantitative assessment of regurgitant flow in mitral incompetence is difficult and can only be approximative. On the other hand, the mechanism of mitral incompetence may be clearly demonstrated in: - mitral valve prolapse with the characteristic bowing of the posterior leaflet; - rheumatic mitral incompetence with the abnormal valvular thickening showing the post-rheumatic retractile fibrosis; - ruptured chordae with eversion of the tip of one of the values in the left atrium; - infective endocarditis with ruptured chordae and vegetations; - cogenital mitral incompetence where the superiority of 2D echo over M mode is most marked, the apical incidences demonstrating the high VSD, ostium primum defect and cleft mitral valve. The limitations of the method are also discussed.