[Retrospective study of hospitalizations for heart failure in elderly patients in a cardiology service of a general hospital center]. / Analyse rétrospective des hospitalisations pour insuffisance cardiaque chez le sujet âgé dans un service de cardiologie d'un centre hospitalier général.

The results of a retrospective study of patients over 70 years of age admitted to the cardiology department of Meaux Hospital for cardiac failure in 1997 are reported. The cases of 143 patients were analysed with respect to two age groups: 70-79 years, and over 80 years of age. The principal aetiology of cardiac failure in all ages was ischaemic heart disease. Hypertensive heart disease was observed in younger patients and valvular heart disease in the more elderly. No significant gender differences were observed in those affected by this pathology or by left ventricular systolic or diastolic dysfunction between the younger and older patients, men having more systolic dysfunction than women. The main causal factor of decompensation in all ages was supraventricular arrhythmias. From the therapeutic point of view, the prescription of ACE inhibitors was relatively common but at low doses. Re-hospitalisation for cardiac failure was common and observed mainly in patients with low ejection fractions. The average hospital stay was 12.58 days. The hospital mortality was high: 15%. Two year survival was 41% with no difference between patients with systolic or diastolic dysfunction. Pluridisciplinary management should reduce the number of re-hospitalisation, improve the quality of life and, perhaps, improve survival.

Flecainide-associated pneumonitis with acute respiratory failure in a patient with the LEOPARD syndrome.

Antiarrhythmic agents can cause pneumonitis. Flecainide is a rare cause of hypersensitivity pneumonitis, and few cases have been reported. We describe a case of interstitial hypoxaemiant pneumonitis probably related to flecainide in a patient with the LEOPARD syndrome, a rare congenital disorder.

[Aortic valve myxoma. Conservative valvular surgery]. / Myxome de la valve aortique. Chirurgie de conservation valvulaire.

The authors report a case of aortic valve myxoma discovered in a 35 years-old patient who suffered a transient ischemic attack. At operation a helicoidal gelatinous mass was found attached to the ventricular side of the right coronary cusp of the aortic valve by a pedicle. Through a mini-sternotomy approach the mass was excised and the cusp was repaired. Recovery was uneventful.

[Association of an epsilon wave and syncope]. / Association d'une onde epsilon et d'une syncope.

BACKGROUND: Epsilon waves, rarely observed in clinical practice, result from late potentials favoring the development of ventricular rhythm disorders by reentry. CASE REPORT: A 53-year-old man with sequellar myocardial infarction experienced a syncope. The surface ECG recorded an epsilon wave. Programmed ventricular stimulation before and after anti-arrhythmia drugs triggered ventricular tachycardia which was hemodynamically poorly tolerated. A defibrillator was implanted and confirmed retrospectively the rhythmic origin of the syncope. DISCUSSION: The association of an epsilon wave and syncope should guide the etiology search towards severe ventricular rhythm disorders such as ventricular tachycardia. An electophysiologic study is required in order to determine the appropriate therapy and thus help avoid possibly fatal recurrence.

[Thiamine deficiency. A cause of cardiac insufficiency not to be ignored]. / La carence en thiamine. Une cause d'insuffisance cardiaque à ne pas méconnaître.

Thiamine deficiency is one of the classical causes of high out put for heart failure. Deficiency of this vitamin may be nutritional or secondary to alcoholic intoxication. We felt it would be interesting to describe a typical case of cardiac beriberi in order to recall the clinical presentation and the pathophysiology.

[Adaptation to effort in patients with chronic cardiac insufficiency; study by post-exercise Doppler echocardiography, comparative results with a control population]. / Adaptation à l'effort chez l'insuffisant cardiaque chronique; étude par échocardiographie doppler post-effort, résultats comparatifs avec une population témoin.

Adaptation to exercise was studied by post-exercise Doppler echocardiography in patients with chronic cardiac failure and an apparently healthy control population matched for age. This post-exercise Doppler echocardiographic method initially introduced for the detection of myocardial ischaemia has already been validated in normal subjects for the analysis of haemodynamic changes caused by exercise providing the data is recorded in the first 5 minutes following recovery in the recumbent position. Eleven patients with chronic cardiac failure in NYHA classes II or III with a mean age of 54 +/- 11 years and 6 controls (mean age: 46 +/- 9 years) were investigated. The patients had been stabilised for at least 3 months with a vasodilator and diuretic therapy: the control subjects had no medication. After bicycle ergometry performed to 70% of maximum capacity, the subjects were positioned in the left lateral recumbent position. Doppler echocardiography was then performed in the immediate recovery phase. When compared to the control population, the patients with cardiac failure had a reduced chronotropic reserve, a smaller increase in the parameters of myocardial contractility (maximal aortic velocity, maximal aortic acceleration and left ventricular fractional shortening) without an increase in left ventricular end diastolic dimensions in subjects with severe dilatation under basal conditions (left ventricular end diastolic dimension 69 +/- 3 mm). This result suggests the absence of a Frank-Starling effect. The lack of adaptation of the peripheral vascular system was demonstrated by the lack of reduction of left ventricular end systolic stress, already greatly increased at rest (176 vs 77 +/- 10 g/cm2 for patients, compared with controls; p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Improvement of subendocardial myocardial perfusion after percutaneous transluminal coronary angioplasty. A myocardial contrast echocardiography study with correlation between myocardial contrast reserve and Doppler coronary reserve.

BACKGROUND: After angioplasty coronary reserve improves but does not normalize in most patients. The purpose of this study was to examine before and after angioplasty coronary reserve and transmural myocardial blood flow distribution using myocardial contrast echocardiography. METHODS AND RESULTS: Twelve patients with left anterior descending coronary artery stenosis were investigated before and immediately after angioplasty. A Doppler catheter was placed in the proximal segment. Myocardial contrast echocardiography was performed by imaging the septum in M mode in a parasternal view using a 3.0-mL bolus of sonicated amidotrizoate sodium meglumine through the guiding catheter. The gray level before injection was subtracted from the gray level after injection to maximize contrast time-intensity curves. The area under the curve was used as an indicator of myocardial blood flow, and subendocardial/subepicardial ratios were measured. After baseline measurements were obtained, Doppler and echographic data were recorded after a bolus infusion of papaverine into the left main coronary artery. The same protocol was performed in patients after angioplasty and in five control subjects with normal coronary arteries. Before angioplasty, echocardiographic and Doppler coronary reserve were 2.57 +/- 0.48 and 2.54 +/- 0.57, respectively. Both increased after angioplasty to 3.65 +/- 0.57 and 3.36 +/- 0.70, respectively (P < .05). Coronary reserve values obtained in patients with these two methods under the different conditions and in control subjects were correlated (r = .81; P = .0001). Before angioplasty, subendocardial/subepicardial septal ratios decreased from 0.80 +/- 0.48 to 0.60 +/- 0.27 after papaverine (P < .05). However, after angioplasty, these ratios tended to increase, from 0.72 +/- 0.27 to 0.92 +/- 0.45 after papaverine, but they did not change in control subjects (1.11 +/- 0.23 to 0.92 +/- 0.11). CONCLUSIONS: These results show that myocardial contrast echocardiography yields flow reserve values that correlate with values obtained using intracoronary Doppler. This technique may be considered as an accurate tool to assess coronary reserve in humans.

Post-exercise Doppler-echocardiographic haemodynamics in idiopathic dilated cardiomyopathy after metoprolol infusion.

1. The physiological effects of the acute administration of a beta-adrenoceptor antagonist in patients with idiopathic dilated cardiomyopathy were assessed by performing post-exercise Doppler-echocardiography study. Eleven patients and six control subjects were studied. According to a double-blind randomized protocol, 5 mg of metoprolol or placebo was administered before cycloergometer exercise. 2. In patients, after metoprolol, a significant decrease in heart rate and systolic blood pressure, as well as in peak aortic acceleration and cardiac output, was observed 2 min after exercise. Left ventricular end-diastolic diameter did not change from baseline values either after placebo or metoprolol. In normal subjects, as compared with placebo, a decrease in heart rate and peak aortic acceleration was observed after metoprolol, whereas systolic blood pressure did not change. A similar increase in cardiac output occurred after metoprolol, as compared with placebo, associated with an increase in left ventricular end-diastolic diameter and stroke volume. 3. Post-exercise Doppler echocardiography is a means of assessing haemodynamic changes occurring during exercise in patients with congestive heart failure. Although acute metoprolol administration does not provide beneficial haemodynamic effects, a decrease in the energy requirements of the heart and a faster recovery after exercise may participate in the long-term beneficial action of beta-adrenoceptor antagonists.

[Doppler echocardiographic evaluation of mitral flow velocity and prognosis of cardiac insufficiency]. / Vitesses du flux mitral évaluées en échocardiographie doppler et pronostic de l'insuffisance cardiaque.

The aim of this study was to determine the role of Doppler echocardiography in establishing the prognosis of Stages to 4 cardiac failure. The echocardiographic indices of left ventricular filling were correlated with catheter data and the 2 year out come of patients. The study population included 54 patients examined prospectively in the context of an evaluation of their cardiac failure. Two years after the initial examination, 19 patients were dead or transplanted. Of the remaining 35 patients, 18 were reevaluated at 6 months. Of the echocardiographic parameters, "hyper normal" mitral flow with a high E/A ration indicated poor prognosis; when E/A > 2, the one year survival was 50% and the 2 year survival 42%. There was overlap between the groups of dead or transplanted and surviving patients only when the E/A ratio was between 2 and 3. The patients with E/A < 2 were all alive without any major events at 2 years. All patients with E/A > 3 had a poor prognosis. The E/A ratio was closely correlated with pulmonary capillary pressure levels (p < 0.001, r = 0.55) and lees closely with cardiac index (p < 0.05, r = 0.4) and radionuclide ejection fraction (p < 0.05, r = 0.28). After 6 months' vasodilator treatment with an angiotensin converting enzyme inhibitor (captopril) the E/A ratio decreased significantly from 1.85 +/- 0.78 to 1.0 0.55 (p < 0.02). A "hyper-normal" mitral flow is related to many factors, including high left ventricular filling pressures, mitral regurgitation and reduced left ventricular compliance. This appearance of mitral flow is a poor prognosis factor in severe cardiac failure.

[Implantation of an endoprosthesis for the repair of stenosis of valved tube between right ventricle and pulmonary artery]. / Mise en place d'une endoprothèse pour correction d'une sténose sur un tube valvulé ventricule droit-artère pulmonaire.

The author report the case of a 35 year old man who had undergone a Rastelli procedure in 1976 for transposition of the great arteries and who required indertion of a stent for stenosis of the valved right ventricular-pulmonary artery conduit. The patient presented with florid signs of right ventricular failure due to degenerescence of the conduit which had a 60 mmHg pressure gradient between the right ventricle and the pulmonary artery. This palliative procedure was decided upon given the high risk of reoperation. The valved conduit was dilated with a balloon catheter before insertion of a Gianturco stent (30 mm diameter and 50 mm long) to cover both conduit and the valvular apparatus. The insertion of the stent was easy with immediate normal expansion and the procedure was well tolerated. After insertion of the stent, the right ventricular-pulmonary artery pressure gradient fell from 60 to 35 mmHg. Angiographic control one month later showed a sustained hemodynamic result with a perfectly patent stent. The patient was pauci-symptomatic when reviewed six months after the procedure.

[Role of antithrombotic agents after myocardial infarction]. / La place des antithrombotiques après un infarctus du myocarde.

Thrombosis is the causal mechanism of myocardial infarction: severe atherosclerotic narrowing, ulceration of the atherosclerotic plaque and disequilibrium between pro and antithrombotic factors, predispose to this complication. Recurrent myocardial infarction is a common complication in the year following an initial event: the risk is higher when the diseased artery has been recanalized in the acute phase. Reocclusion of the recanalized artery without signs of infarction is also a common occurrence. It was therefore logical to have striven over the years to prevent reinfarction and/or rethrombosis after reperfusion. Mechanical methods have not been crowned with resounding success and antithrombotic drugs are the only products associated with real benefits in this prevention. In this article, the authors review the efficacy of aspirin and vitamin K antagonists in the prevention of recurrent myocardial infarction; the data in favour of an efficacy of aspirin in preventing early reinfarction is also analysed; finally, results suggesting a benefit of platelet antiaggregant therapy (Flurbiprofen or aspirin) on the risk of reocclusion after therapeutic recanalisation are also assessed.

[Which medical treatment after myocardial infarction?]. / Quel traitement médical après un infarctus du myocarde?

Patients leaving the hospital after a myocardial infarction are given a prescription containing several drugs. The purpose of this paper is to determine which of these drugs have a proven value and for which types of patients. Antithrombotic agents (be it acetyl-salicylic acid or antivitamin K drugs) have been shown to be efficient after a myocardial infarction. Beta-blockers are certainly useful, notably in cases with severe necrosis. Conversely, the usefulness of calcium antagonists for secondary prevention has not been demonstrated and indeed, it seems probable that the drugs of this class might be harmful in patients who had severe infarction. There is little divergence concerning the necessity to control the risk factors for coronary atherosclerosis after a myocardial infarction. The evidence is strong concerning giving up smoking; it is intuitive as regards controlling arterial hypertension and more controversial as regards the need for lowering blood cholesterol levels. The systematic prescription of antiarrhythmic agents after myocardial is certainly noxious. Finally, prospects are now opened by the prevention of left ventricular remodelling under treatment with angiotensin-converting enzyme inhibitors.

[Prehospital thrombolytic therapy]. / Thrombolyse préhospitalière.

The objective of pre-hospital thrombolytic therapy is to reduce the delay between the time of initial contact with a patient with acute myocardial infarction and the administration of thrombolytic therapy. To validate feasibility and utility. Its feasibility has been demonstrated in many pilot studies throughout the world. The utility of the technique is the gain of nearly 60 minutes compared with patients treated on hospital admission; another advantage is the fact that emergency medical teams are alerted to their new medical responsibility. On the other hand, there are no published reports showing a decreased infarct size or mortality when compared with in-hospital thrombolysis. The results of studies currently under way are expected in the near future and should throw new light on the value of this technique. Nevertheless, pre-hospital thrombolysis is only one facet in the improved management of acute myocardial infarction.

[Valvotomy and congenital aortic valve stenosis. Long-term results]. / Valvulotomie et sténose aortique orificielle congénitale. Résultats à long terme.

Twenty nine patients (average age 11 years) underwent valvotomy for congenital valvular aortic stenosis from 1967 to 1983. The medium and long-term results were analysed retrospectively: 14 children have been reoperated; 11 for restenosis and 3 for aortic regurgitation after an average period of 11 years. Thirteen of the other 15 patients have been regularly followed-up for about 10 years: there are 7 good results, 3 average results and 3 restenoses. One patient was lost to follow-up after 9 years and the other patient died secondarily of a non-cardiac cause. This series was compared to a previous one of 35 cases of valvular aortic stenosis who underwent valvotomy between 1954 and 1964. There were 6 deaths in the perioperative period and 6 during follow-up (on average 11 years after surgery), including 3 sudden deaths. Eleven patients were reoperated: 2 for endocarditis, 5 for restenosis and 4 for aortic regurgitation (on average after 13 years). Three patients were lost to follow-up and there are 9 survivors who have not been reoperated (average follow-up 27 years): 5 of these patients were reexamined; there were 2 excellent results, 2 average results and 1 restenosis. These results show that conservative surgery of congenital valvular aortic stenosis is now a low risk procedure in children, but it is a palliative solution. The main problem is that of follow-up to detect restenosis because of the risk of sudden death. This follow-up is much easier since the introduction of Doppler echocardiography, eventually associated with exercise stress testing in doubtful cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of chronic left ventricular insufficiency]. / Traitement de l'insuffisance ventriculaire gauche chronique.

Left ventricular failure results from many myocardial diseases: the symptoms of left ventricular failure are the consequence of adaptations which the left ventricle and circulatory system activate to counteract the initial myocardial disease. The aims of treatment of cardiac failure are diverse depending on whether treatment is directed to correct the initial myocardial disease, its myocardial consequences, its circulatory consequences or, more simply, the patient's symptoms. The ideal treatment of cardiac failure would include a drug acting on the cause, a drug restoring left ventricular contraction and relaxation adapted to the conditions of cardiac load, a drug correcting regional blood flow disturbances and a drug relieving symptoms related to salt retention. An ideal drug for chronic left ventricular failure does not exist, and so treatment is a composite effort. Should it be in first intention? This is the current trend.

[The treatment of chronic left ventricular insufficiency]. / Traitement de l'insuffisance ventriculaire gauche chronique.

Left ventricular failure is caused by a variety of myocardial diseases and its symptoms results from adjustments attempted by the left ventricle and the circulatory system to cope with the initial myocardial pathology. Treatment of heart failure has various objectives, depending on whether one tries to correct the initial myocardial disease, or its consequences on the myocardium, or its repercussions on blood circulation, or, more simply, to alleviate the symptoms experienced by the patient. The ideal treatment of heart failure would include a drug acting on its cause, another drug to restore a degree of contraction and relaxation adjusted to the amount of load, a third drug bringing back to normal a perturbed peripheral circulation and a fourth drug to relieve the symptoms due to sodium retention. Such a treatment does not exist, and the management of chronic left ventricular failure can only be composite. Should it be prescribed from the start? This, increasingly, is the current trend.

[Mianserin in acute cardiopathies. 27 cases recorded in a medical intensive care unit]. / La miansérine dans les cardiopathies aiguës. 27 cas recueillis dans une unité de réanimation médicale.

The cardiovascular tolerance of mianserin, a tetracyclic antidepressant with anxiolytic properties, at a dose of 30 to 90 mg/day, is studied in 27 patients affected by acute cardiopathies and attended for two months by a cardiologist and a psychiatrist. From the cardiovascular point of view progression is as usual, with two deaths from recurrence of a massive infarct, prognosis in agreement with the literature. A clinical examination, the electrocardiogram and Holter monitoring did not reveal any side effects. Psychiatric progression is favourable, in conformity with studies of the antidepressive and anxiolytic properties of mianserin. These results are compared with those of tricyclic antidepressants usually employed up to now in similar cases, with their well-known cardiovascular risks, particularly in the case of an overdose. The authors thus suggest the use of mianserin in the acute phase of all cardiopathies, in cases of depression and/or anxiety, because it is efficacious and well-tolerated, whereas a tricyclic antidepressant would not be easy to handle, dangerous, indeed formally contra-indicated. By extension, they suggest its use in chronic cardiopathies.