[Myocardial infarction with normal coronary arteries: role of transesophageal echocardiography]. / Infarctus du myocarde à artères coronaires saines: place de l'échographie cardiaque transcesophagienne.

We report the case of 74 years-old female patient hospitalized for a ST+ acute coronary syndrome with normal coronary angiography. The association of a patent foramen ovale, a deep venous thrombosis and a pulmonary embolism led us to conclude the diagnosis of paradoxical coronary embolism. This case allows us to remind different etiologies to be considered in case of myocardial infarction with normal coronary arteries, and the interest of transesophageal echocardiography for the diagnosis of its etiology.

[Pheochromocytoma simulating myocardial infarct. Apropos of a case]. / Phéochromocytome simulant un infarctus du myocarde. A propos d'un cas.

The authors report the case of a pheochromocytoma in a 67 year old man in whom the initial clinical presentation suggested myocardial infarction. Pheochromocytoma is usually an adrenal tumour with a very variable clinical symptomatology. It is very rare for cardiac disease to be a presenting symptom. The diagnosis was suggested by major blood pressure abnormalities occurring after starting medical treatment for infarction. Pheochromocytomas may cause serious cardiovascular disorders. The diagnosis must be suspected in the presence of atypical signs, an essential requirement to reduce the mortality of the disease.

[Effects of hormone replacement treatment of menopause on the risk of venous thromboembolic disease]. / Les effets du traitement hormonal substitutif de la ménopause sur le risque de maladie thrombo-embolique veineuse.

Post-menopausal hormone replacement therapy increases the risk of venous thrombo-embolism 2- to 4-fold. The risk is highest in the beginning of the exposure to hormones and disappears rapidly after interruption of treatment. However, the increased risk remains low in absolute value and has to be weighed against coronary artery disease and post-menopausal osteoporosis.

[Acute myocarditis caused by toxoplasmosis simulating infarction. Apropos of a case]. / Myocardite aiguë à toxoplasme simulant un infarctus. A propos d'un cas.

Acute myocarditis due to toxoplasmosis infection has been previously reported, usually in patients suffering from immuno-depression. Cardiac involvement by toxoplasmosis is rare in subjects with a normal immunological status. The authors report the case of a 16-year-old patient without immuno-depression with acute myocarditis caused by toxoplasmosis simulating myocardial infarction.

[Primary aspergillus endocarditis]. / Endocardite aspergillaire primitive.

A 38-year old man was admitted for investigation of suspected endocarditis presenting with two cerebrovascular accidents and pyrexia. The initial clinical, echocardiographic and infectious investigations were normal, apart from a neutrophilic leukocytosis. The clinical course was marked by the recurrence of systemic embolism in the lower limbs, the appearance of cervical and axillary lymphadenopathy and, within a short period of time, of massive aortic valve vegetations. The diagnosis of aspergillosis was made from the culture of a peripheral embolus recovered by a Fogarty catheter and this was confirmed by the positivity of serological investigations. The patient died within two months despite antifungal therapy. Aspergillus endocarditis is characterised by its rapid progression, the volume and embolic tendency of the vegetations, the relative inefficacy of medical therapy and the potential benefits of early surgical management.

Percutaneous transluminal venous angioplasty in occlusive iliac vein thrombosis resistant to thrombolysis.

Systemic thrombolysis is less than optimal in total occlusions of the iliac vein in which patency is 20% or less. We describe an interventional therapeutic procedure that may be effective in such cases. We selected 18 patients (average age, 29.5 years; range, 16 to 71 years) with complete iliac vein occlusion that persisted after 24 to 48 hours of systemic thrombolysis (streptokinase 100,000 U/hr). The ipsilateral femoral vein was punctured, and a guide wire was gently advanced through the thrombus into the inferior vena cava. Multiple inflations were performed with a balloon catheter that was advanced on the wire. A temporary vena cava filter was placed as a protection against possible embolic migration. Systemic thrombolysis was administered for 24 to 48 hours. Control venography and pulmonary angiography were performed. Venography showed good recanalization in seven cases, incomplete recanalization in five cases, and failure in six cases. Patency was maintained for a long time (15.6 months). In conclusion, (1) percutaneous transluminal venous angioplasty is a valuable adjunct to systemic thrombolysis when the latter alone fails; (2) segmental flow and mechanical obstruction were the critical factors, since the pharmaceutical factors were held constant, and (3) a more aggressive incremental interventional strategy warrants consideration.

[Preventive treatment of systemic embolic complications of atrial fibrillation]. / Le traitement prophylactique des complications emboliques systémiques de la fibrillation auriculaire.

Non-valvular atrial fibrillation multiplies the risk of presumed embolic events by a factor of four. The hemorrhagic risk of anticoagulant treatment varies considerably and its prophylactic efficacy was not tested in any randomised trial before the end of 1989. The recommendations of experts at that time recognised that data were inadequate. The publication since of four randomised trials involving 3,049 patients has provided a more objective base for management decisions, highly in favour of the anticoagulation of cases of non-isolated atrial fibrillation in the absence of contraindications.

Predictive factors of effectiveness of streptokinase in deep venous thrombosis.

In a prospective study, 174 patients (118 women and 56 men, average age 44 years, range 14 to 82) with proximal extensive thrombosis received streptokinase (100,000 U/hour) for an average of 2.8 days (range 0.5 to 7) through the catheter of a temporary caval filter. Twenty-seven of 45 (60%) patients with nonocclusive clots were completely free of clots at the second phlebography versus 17 of 116 (14%) with occlusive clots (p less than 0.001). Among nonocclusive clots, proximal ones (caval, iliac and femoral) were more easily lysed than popliteal clots (88 of 116 [76%] vs 26 of 58 [45%]; p less than 0.001). In 41 of 132 (31%) patients, a daily injection of contrast medium through the filter-carrying catheter enabled the observation of a clot in the filter, which was lysed by streptokinase. Seventy patients with follow-up greater than 2 years (median 34 months) were examined clinically. Nineteen of 22 (86%) patients with venograms free of clots at discharge were free of clinical sequelae versus 16 of 48 (33%) without normal venograms (p less than 0.001). It is concluded that: (1) in the case of occlusive clots, only a few patients were normalized after streptokinase; (2) proximal nonocclusive clots were most effectively lysed; (3) when venograms were free of clots at discharge, the majority of patients did not have venous sequelae at follow-up; and (4) embolic migration seems to occur frequently with streptokinase.

Use of a new removable vena cava filter in order to prevent pulmonary embolism in patients submitted to thrombolysis.

The authors present a removable vena cava filter that may be introduced percutaneously, is atraumatic to the venous wall, and permits the simultaneous use of thrombolytic therapy. Sixty-five patients were studied: 42 cases of pulmonary embolism with threatening venous thrombosis; 23 cases of phlebitis associated with an ilio-caval thrombus without pulmonary embolism. The filter was introduced 38 times femorally and 27 times by a jugular approach. In 16 cases (24.6%) clots broke loose, were effectively caught by the filter, and were progressively dissolved during thrombolytic therapy. The filter remained in place on average 4.5 +/- 1.2 days. The filter was removed in all cases without provoking the recurrence of pulmonary embolism. Two deaths, not related to pulmonary embolism, occurred during hospitalization. Phlebography, performed in all cases before and after treatment, showed a significant decrease of the phlebographic score (10.88 +/- 0.82 vs 6.77 +/- 0.86, P less than 0.001). The same was observed in 40 patients who underwent a pulmonary angiography before and after treatment (Miller index = 17.04 +/- 0.73 vs 5.49 +/- 0.87, P less than 0.0001). After removal of the filter, no sign of pulmonary embolism was detected on lung scan in the 23 patients with ilio-caval thrombus alone. More than 5 g (100 ml)-1 of haemoglobin was lost by 15.38% of patients. All patients were followed-up for a mean of 7.12 +/- 1.3 months; in no case was there any clinical recurrence of pulmonary embolism. Thus this device allows an effective temporary filtering of the vena cava.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative cardiac effects of intravenous bolus of ipratropium bromide (itrop) and atropine sulfate in 22 patients.

At the present time, there is no satisfactory pharmacological treatment for arrhythmia or conduction disorders induced by or aggravated by vagal hypertonia. The limited duration of action of the atropine derivatives currently available justifies the development of new compounds with expected longer acting duration. The aim of this study was to compare the effects of a single blind intravenous injection of ipratropium bromide to those of atropine sulfate in 22 patients. These patients were studied with continuous Holter recordings for three days. During the second and the third nights (patient sleeping), boluses of atropine (0.03 mg/kg) and of ipratropium bromide (0.03 mg/kg), respectively, were added to a continuous saline intravenous infusion. Accurate ECG analysis allowed determination of maximal heart rate peak, timing of maximal heart rate, variations in sinus cycle length, atrioventricular conduction, and durations of drug action. A nonsuggestive questionnaire was presented to patients to detect possible occurrence of side effects. The mean maximal heart rate rose significantly (p less than 0.001) for atropine (+46.2%) and for ipratropium bromide (+57.4%). The effects obtained with ipratropium bromide on the heart rate lasted nearly twice as long as those obtained with atropine (respectively, 120 +/- 38.4 min and 70 +/- 30 min- for the pharmacological half-life). Common minor muscarinic side effects (dryness of the mouth) were noted with the two drugs. In conclusion, this comparative intraindividual study confirmed the prolonged vagolytic effects of intravenous ipratropium bromide, which may be valuable in the treatment of patients with vagally mediated automaticity and conduction disturbances.

[New inotropic drugs in chronic cardiac insufficiency: progress or wrong track]. / Les nouveaux inotropes dans l'insuffisance cardiaque chronique: progrès ou faux pas.

The first results of the long-term treatment of chronic heart failure with inotrope positive medications are disappointing, especially in that survival is not prolonged and even a greater mortality is suggested. Is it because of the regular failure of specific medications, of a class of medications or because the overall concept of inotropism stimulation during chronic heart failure should be condemned? The mechanisms of inotropism of normal muscles or muscles in human chronic heart failure are reviewed as well as the various pharmacological means available to stimulate inotropism.