[The value of repeated determinations of brain natriuretic peptide for the diagnosis of unstable angina]. / Intérêt des dosages répétés du brain natriuretic peptide pour le diagnostic d'angor instable.

The diagnosis of unstable angina (troponine undetectable) is often difficult in the absence of electrocardiographic changes after suggestive chest pains. The object of this study was to analyse the kinetics of Brain Natiuretic Peptide (BNP) during acute coronary syndromes (ACS) without ST elevation. Plasma BNP was measured every 6 hours for 48 hours in 65 patients admitted for suspicion of ACS without ST elevation and without clinical, radiological or echocardiographic signs of left ventricular dysfunction. The results of BNP measurements were masked until the final diagnosis was established on the usual investigations (ECG changes, troponine I values, myocardial scintigraphy, coronary angiography). These investigations identified 3 groups of patients: non-Q wave infarction (group A: 19 patients), unstable angina (group B: 21 patients) and non-coronary chest pain (group C: 25 patients). The peak BNP was significantly higher in groups A (210 +/- 172 pg/ml) and B (152 +/- 159 pg/ml) than in group C (16 +/- 14 pg/ml). However, the BNP was normal or only slightly increased (< 50 pg/ml) in 25% of cases of ACS. Analysis of the kinetics of BNP was much more discriminating: early increase after the pain, peak between the 14th and 24th hours (19th hour on average), followed by a progressive decrease. The kinetics were identical in Groups A and B, contrasting with the flat profile of the curve in group C. A change of > 20 pg/ml in BNP was a better criterion of ACS with a diagnostic accuracy > 90% than increased troponine (group A) or undetectable troponine (group B). The authors conclude that BNP kinetics is a new and reliable diagnostic marker of unstable angina when the usual criteria of ACS are not present (notably a normal ECG and undetectable troponine).

[Myocardial infarction due to spontaneous coronary dissection during the postpartum period]. / Infarctus du myocarde par dissection coronaire spontanée lors du post-partum.

The authors report the case of a 34 year old woman, admitted to hospital because of myocardial infarction two months after delivery of her fifth child. The infarction was caused by spontaneous dissection of the left main coronary and left anterior descending arteries. Twenty-three months later, the patient was well with medical therapy. This case is an example of spontaneous post-partum coronary dissection which is the commonest cause of infarction occurring in that period. The physiopathology of this complication is not fully understood. The prognosis is poor, lethal in two thirds of cases. However, it must be emphasised that coronary dissection may regress spontaneously. Patients were previously referred systematically for surgery, but now it is usually reserved for cases with persistent myocardial ischaemia despite medical therapy. Angioplasty may be preferred despite the risks and may be successful in some cases.

[Spontaneous reduction of late chronic atrial fibrillation after mitral valvuloplasty. Echocardiographic evidence of the restoration of mechanical atrial activity]. / Réduction spontanée d'une fibrillation auriculaire ancienne à distance d'une valvuloplastie mitrale, Evidence ultrasonographique de la reprise d'une activité auriculaire mécanique.

Spontaneous, long lasting reduction of chronic permanent atrial fibrillation, usually complicating rheumatic valvular heart disease, has rarely been described in the literature. Its mechanism is unclear. In practice, the question is to determine whether the electrical activation coincides with restoration of a mechanical atrial contraction. The authors report the case of a woman with mixed rheumatic aortic and mitral valve disease (essentially mitral stenosis), in whom reversion to sinus rhythm was observed after 9 years of atrial fibrillation and which was long lasting (at least 9 months), and, above all, accompanied by atrial contraction documented for the first time to the best of the authors' knowledge, by Doppler echocardiography.

[Myocardial infarction in a pregnant woman during salbutamol therapy]. / Infarctus du myocarde chez une femme enceinte au cours d'un traitement par salbutamol.

The authors report the case of a 31 year old woman at 30 weeks' gestation who developed a non-Q wave postero-lateral myocardial infarction during treatment with salbutamol. There were no complications and delivery took place at term normally. Coronary angiography was performed 3 months post-partum and was normal: the Methergin test was negative. Myocardial ischaemia occurring during treatment with a beta-2 mimetic in pregnancy is rare and hardly ever progresses to myocardial infarction. The usual mechanism of ischaemia is an imbalance of myocardial oxygen demand and supply. Myocardial oxygen consumption is naturally increased during pregnancy and excess intracellular calcium secondary to the beta-1 stimulation occurring with the use of beta-2 mimetic drugs further aggravates matters. This hypothesis raises the question of the value of calcium inhibitors in these forms of myocardial ischaemia.

[Syncopal ventricular tachycardia complicating paroxysmal atrial fibrillation in severe myocardial ischemia]. / Tachycardies ventriculaires syncopales compliquant une fibrillation auriculaire paroxystique lors d'une ischémie myocardique sévère.

The authors report two cases of spontaneous paroxysmal atrial fibrillation closely followed by syncopal ventricular tachycardia resulting in cardiac arrest requiring defibrillation. Both patients, men aged 62 and 64 years, had a past history of myocardial infarction without arrhythmias; atrial fibrillation occurred during severe myocardial ischaemia; coronary arteriography showed tight stenoses of the left main coronary artery with normal left ventricular function. Ventricular tachycardia (or fibrillation) during spontaneous paroxysmal atrial fibrillation is a rare occurrence. This sequence of events has been described in patients with accessory conduction pathways or in hypertrophic cardiomyopathy. It is an exceptionally rare complication of ischemic heart disease with only a very few previously reported cases. Myocardial ischaemia is probably the cause of the arrhythmia in together with irregularity of the ventricular contractions responsible for long cycle-short cycle sequences which are particularly arrhythmogenic and changes in sympathetic tone.

[False aneurysm of the left ventricle during the acute phase of myocardial infarction: diagnosis by transesophageal echocardiography]. / Faux anévrysme du ventricule gauche à la phase aiguë d'un infarctus du myocarde: diagnostic échocardiographique par voie transoesophagienne.

The authors report a case of myocardial infarction complicated by a false aneurysm of the posterior wall of the left ventricle, the diagnosis of which was confirmed, for the first time, by transesophageal echocardiography (TEE) which provided better definition of the anatomical features of the lesion: visualisation of the particularly wide neck (5 cm) and the site of rupture of the myocardium; demonstration of the presence in the false aneurysm with a thin pericardial wall of a large thrombus of different acoustic density, itself overlain by swirling whorls. Colour Doppler combined with TEE clearly showed the acceleration of flow at the neck and its slowing in the newly formed cavity. Once the diagnosis was made, the patient rapidly underwent surgery with a successful outcome. The quality of the images obtained without risk by TEE suggests the important role which this investigation could play in the future in the diagnosis of certain mechanical complications of myocardial infarction.

[Unstable angina and infarction without Q wave treated with verapamil: value of the early exercise test]. / Angor instable et infarctus sans Q traités par vérapamil: intérêt de l'épreuve d'effort précoce.

Twenty patients aged 56.8 +/- 10 years, hospitalised for unstable angina (12 cases) or infarct without Q wave (8 cases) were treated with IV heparin, aspirin and oral verapamil. The clinical syndrome was controlled by verapamil in 16 cases out of 20 (80% of cases) at the dosage of 360 mg/d in 14 patients and of 480 mg/d in two. An exercise ECG, limited by symptoms, was obtained in 18 patients (90%) between the 8th and 12th day. Coronary arteriography was considered to be indicated in three sets of circumstances: recurrence of angina resistant to nitroglycerin, positive exercise ECG with verapamil, persisting despite triple therapy or strongly positive exercise ECG (total duration less than or equal to 6 minutes). An infarct complicated the early course in 4 patients (20%): twice following angioplasty, once following exercise ECG (spastic angina) and once during triple therapy (refractory angina). Hospital and mid-term (18 +/- 6 months) mortality was nil. With verapamil, the absence of recurrence of angina together with a negative exercise ECG enabled the identification of a large group of patients (40%) with a low risk of a subsequent major accident and in whom early and routine coronary arteriography is probably not indispensable.

[Anomalies of the T waves induced by flecainide]. / Anomalies des ondes T induites par le flécaïnide.

Flecainide is a class I antiarrhythmic agent which depresses depolarization and conduction velocities in myocardial and Purkinje's fibres, thereby extending their refractory period. As the drug belongs to the IC group, it may increase--moderately as a rule--the duration of QRS, but it does not alter the action potential duration and therefore does not increase the JT interval. In 3 patients treated with flecainide we observed a peculiar alteration in the shape of T waves, the peak of which was flattened and notched, forming a double hump. This abnormality, most clearly visible on precordial leads, remained isolated with no changes in other electrocardiographic parameters. It appeared independently of any circumstance likely to modify repolarization. It remained stable throughout treatment with flecainide and vanished when the drug was discontinued. It was regularly observed with the recommended therapeutic doses (200-300 mg/day) and was unaccompanied by signs of toxicity. To our knowledge, these T wave abnormalities have not yet been reported. Yet they deserve to be known and correctly interpreted, since they reflect impregnation of the myocardium by the antiarrhythmic agent which should not be withdrawn on this account.

[Angina at rest without significant changes in the per-critical ECG in coronary insufficiency]. / Angor de repos sans modifications significatives de l'ECG per critique dans l'insuffisance coronaire.

In coronary patients angina pectoris at rest is usually attended by clear changes in repolarization, and in the absence of such changes clinicians are justifiably reluctant to assert that the constrictive chest pain is due to ischaemia. However, a number of concordant data indicates that in some cases myocardial ischaemia--whether spontaneous or induced by the ergonovine test or by coronary angioplasty--may cause an anginal pain that proceeds without significant alterations in repolarization and indeed, without any changes in ECG tracings. Prior to making a firm diagnosis of this type of angina, several causes of error must be excluded, the main one being that repolarization disorders are labile and may have disappeared whilst the anginal pain persists. But above all, the ischaemic episode that accompanies angina must be documented by haemodynamic, angiographic, scintigraphic or echocardiographic data. The pathogenesis of angina at rest occurring in coronary patients and without changes in per-critical ECG is still imperfectly known and probably complex. The authors review several possible mechanisms: the pain perception threshold may be lowered, the collateral circulation may be highly developed, and the ischaemic episode may be so discreet and/or controlled by treatment, or so evenly distributed between two opposite territories that no electric gradient is generated.

[Aneurysm of the interauricular septum]. / Anévrysme du septum interauriculaire.

In reference to three personal cases of interatrial septum aneurysm discovered on ultrasonography performed for the diagnosis of a cerebral embolism, the authors describe the positive diagnosis criteria, in mono- and bi-dimensional mode, of this abnormality, as well as related data obtained from catheterization, angiocardiography, and phonocardiography. This malformation, the frequency and pathogenesis of which still remain, today, difficult to evaluate, may be at the origin of complications, especially embolic migrations, systemic and also pulmonary, supraventricular rhythm disorders, interatrial shunt, reduced ventricular filling. Once established, the diagnosis is the subject of many controversies: if plain monitoring appears logical in asymptomatic forms, the occurrence of a systemic embolism makes it difficult to choose between surgical treatment and long-term anticoagulant therapy.

[Auricular fibrillation: a cause of reversible myocardiopathy]. / La fibrillation auriculaire: une cause de cardiomyopathie réversible.

A chronic supraventricular tachycardia may alone be responsible for a picture of severe congestive cardiac insufficiency, which is totally reversible after return to a sinus rhythm. The two cases reported here emphasize this particular fact, the physiopathology of which still remains unknown. There is also a prognostic advantage to such cases: in the presence of a congestive cardiopathy with atrial fibrillation, apparently idiopathic, it is important to try to obtain a sinus rhythm and to study from a distance the left ventricular performance indexes which may return to normal after regularization of the rhythm.

[Splenic abscess disclosing endocarditis]. / Abcès splénique révélateur d'une endocardite.

A 54 year old man, hospitalised for thoraco-abdominal pain resulting from a septicemia which gives positive hemocultures for streptococcus D Bovis, is diagnosed to have a splenic abscess which will require splenectomy. At the same time, an endocarditis develops and gets worse, with auriculo-ventricular blockade and, especially, major aortic insufficiency, which is the cause of death by a brutal and massive pulmonary oedema. In the progression of an endocarditis, the occurrence of a splenic abscess, primary localisation of the initial septicemia or the secondary of an arterial septic embolism, is a rare contingency compared to the frequency of splenomegaly or splenic infarction: less than 2 percent of the cases in the literature. This very atypical and exceptional case serves as a reminder, on the one hand, of the diagnostic inadequacy of echocardiography which cannot visualise vegetation in the course of progressive endocarditis, and, on the other, of the prognostic importance of auriculoventricular blockade in septal and aortic endocardial lesions.

[Septal rupture in elderly patients. Apropos of 2 cases treated surgically in the acute phase of myocardial infarction]. / Ruptures septales du sujet âgé. A propos de 2 cas opérés à la phase aiguë d'un infarctus.

Two cases of interventricular septal rupture (VSR) in elderly patients (71 and 74 years) occurring at the 5th and 12th day of primary postero-inferior myocardial infarction, were reported. The diagnosis was made at 2D echocardiography and confirmed at catheterisation with coronary angiography. Good surgical results were obtained after operation 72 and 12 hours after VSR (9th and 12th infarct days, respectively): the first patient had a good outcome with a 2 year follow-up, but the second patient died in the 55th postoperative day, of renal failure. The authors underline the value of 2D echo in the management of acute myocardial infarction and in the detection of VSR. In addition, the advances in intensive care and surgical techniques allow early and complete cure of cardiac lesions with a low hospital mortality and significant functional improvement, even in the elderly patient.

[Rupture of a post-infarct ventricular aneurysm. Apropos of 3 cases cured surgically]. / Rupture d'anévrysme ventriculaire post-infarctus. A propos de trois cas guéris chirurgicalement.

The authors report 3 cases of post-infarction left ventricular aneurysm with localised rupture into the pericardium. The patients (3 men aged 54, 58 and 67 years old) had left ventricular aneurysms (2 anterior, I posterior) which ruptured early, between the second and tenth week. All presented with cardiogenic shock. The diagnosis was made by 2D echocardiography (I case) or by pericardial aspiration and angiography (2 cases). Good results were obtained by surgical evacuation of the hemopericardium and resection of the ventricular aneurysm with a follow-up of 3 to 12 months. The rarity of these cases is underlined: only three other similar cases appear to have been previously reported.

[Pseudoventricular tachycardia linked to a reciprocal antidromic rhythm from Mahaim's fibers]. / Pseudo-tachycardie ventriculaire liée à un rythme réciproque antidromique par un faisceau de Mahaïm.

A 24 year old female presented with paroxysmal pseudo-ventricular tachycardia with wide QRS complexes and complete atrioventricular dissociation. Electrophysiological studies showed a junctional tachycardia with an antidromic reciprocating rhythm. The activation involved Mahaïm nodo-ventricular fibres in the anterograde direction, the nodo-hisian pathway being the retrograde limb of the reentry pathway. The main point of interest of this case was the presence of complete atrioventricular dissociation during tachycardia, the atria remaining in sinus rhythm with the possibility of sinus capture formally excluding the diagnosis of a paraseptal Kent bundle. This reentry mechanism has been previously described and constitutes a differential diagnosis of ventricular tachycardia.

[Constrictive pericarditis secondary to myocardial infarction. Surgical care]. / Péricardite constrictive secondaire à un infarctus du myocarde. Guérison chirurigicale.

The authors report the case of anteroseptal myocardial infarction, complicated by a late pericardial reaction (5th - 10th week), the development of an aneurysm, and, above all, refractory ascites (12th week) found to be secondary to constrictive pericarditis. Pericardectomy and partial resection of the aneurysm were performed. Constrictive pericarditis is rare after myocardial infarction and its relationship to a forme fruste of Dressler's syndrome remains uncertain. The pathogenesis of the constriction is unknown. This complication (only reported once previously) should be recognised because of the surgical management it implies.