[Recurrent mobile thrombus of the ascending aorta diagnosed by transesophageal echocardiography]

The authors report the case of a 32 year old woman with no risk factors for thromboembolism apart from a raised Lipoprotein (a) level, in whom a mobile thrombus of the ascending aorta was diagnosed only by transoesophageal echocardiography after multiple episodes of systemic embolism. After surgical excision the thrombus recurred and death ensued on the 17th postoperative day after multiple visceral embolism despite adequate anticoagulant therapy. This is a rare condition, the outcome of which seems often to be fatal, due to early recurrence irrespective of the treatment (anticoagulant or platelet antiaggregant therapy). This case illustrates the value of systematic transoesophageal echocardiography for the investigation of cerebral or peripheral ischaemic episodes without carotid artery disease and raises the problem of the best way of treating this pathology.

[Doppler echocardiography under dipyridamole after thrombolyzed early myocardial infarction. Comparison with coronarographic data]

The reliability and safety of Doppler echocardiography with dipyridamole (0.84 mg/kg in 10 min) were evaluated in 63 patients an average of 7 days after a thrombolysed early lateral infarct and 24 hours before follow-up coronary arteriography. The aims of the test were the detection of tight stenoses (diameter reduced by more than 75%) affecting the artery responsible for the infarct as well as the other coronary vessels, using the vasodilator action of dipyridamole. The echocardiographic manifestation of induced coronary steal consisted of transitory asynergism in the territory of the artery involved. Clinical tolerability of the test was good. The brief onset of anginal pain was nevertheless seen in 6 patients. Analysis of the zone corresponding to the necrosed area was possible in only 43 cases. Sensitivity of the test for detection of a post-infarction residual stenosis was 64% (39-89) and specificity 90% (79-100). Study of other territories was possible in 59 cases. Sensitivity of the test for the diagnosis of multiple vessel disease was 70% (42-98) and specificity 94% (88-100). In the population as a whole, Doppler study of variations in anterograde mitral flow revealed a sensitivity of 40% (27-53) and specificity of 87% (78-96). Variations in sub-aortic flow were analysed only in the final 27 patients, with a sensitivity and specificity of 100%. The specificity of dipyridamole echocardiography after infarction is good, both for the detection of residual stenosis and that of multiple vessel disease, the chief limiting factor being the impossibility of analysis of the infarcted region in the presence of initial akinesis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic constrictive pericarditis after heart surgery. Apropos of a case]

A case of pericarditis in a 52-year old patient following aorto-coronary shunt surgery is reported which gradually developed into chronic constrictive pericarditis. In this context, the diagnostic criteria of chronic constrictive pericarditis are recalled. The clinical criteria show little specificity; Doppler ultrasound provides good diagnostic information; CT scans and nuclear magnetic imaging can confirm the diagnostic. The post-heart surgery etiology has increased in recent years. The only real treatment is surgical and consists of pericardial decortication.

[Thrombolysis and acute venous thromboembolic disease]

Thrombolytic agents are widely used as first line treatment in severe acute pulmonary embolisms. While their indications are well defined, no controlled trial exists to provide definite evidence of their ultimate effectiveness in terms of mortality. Nevertheless, therapeutic advances and the good results obtained in terms of satisfactory changes in hemodynamic and angiographic parameters have led to renewed evaluation at the present time of the ways in which they are used in thrombo-embolic disease: administration of thrombolytics as repeated boluses in order to decrease the risk of hemorrhagic complications; and extension of the indications of thrombolysis to the venous component of thrombo-embolic disease.

[Value of transesophageal echography in the diagnosis of posterior ventricular septal rupture during the acute phase of myocardial infarction. Apropos of 2 cases]

The authors report two cases of posterior ventricular septal defects complicating acute myocardial infarction diagnosed by transesophageal echocardiography. Transesophageal echocardiography was well tolerated confirmed the diagnosis, and enabled accurate evaluation of the shunt in the transgastric view. The anatomical results guided the surgical approach and correlated well with the operative findings.

[Spontaneous idiopathic pneumopericardium in young patients. Review of the literature. Apropos of a new case]

Spontaneous idiopathic pneumopericardium (SIPP) in young subjects is a rare disorder since, apart from the case described here, only 28 cases have been reported in the literature. It occurs mainly in young adults. The physiopathology of the disorder involves alveolar rupture, as described by Macklin. The symptoms of SIPP are dominated by chest pain, which usually develops suddenly and is combined with dyspnea. Clinical examination is not very helpful, cardiac auscultation detects either pericardial rubbing or a more suggestive metallic sound. Recovery usually occurs without treatment, but there is a risk of long-term recurrence. An unusual complication to be feared is aerial tamponade, which may be life-threatening and calls for emergency draining. The treatment of SIPP involves strict bed-rest, symptomatic treatment of the pain and clinical monitoring.

[Anaphylactic shock complicated by myocardial infarction: side effect of glaphenine?]

The authors report a case of anaphylactic shock complicated by coronary spasm and infarction attributed to glafenine medication in a 43-year-old male patient. The outcome was positive and coronary angiography showed healthy coronary vessels. The ergonovine maleate was negative. A review of the literature confirms the rarity of this complication of anaphylactic shock and study the ECG changes induced by this type of reaction and to analyze the mechanisms responsible for this coronary spasm in this situation. These consists basically of histamine release and prostaglandin-synthesis inhibition.

[Predictive factors of regularization and maintenance of sinus rhythm in chronic atrial fibrillation]

The aim in treating chronic atrial fibrillation, is not limited to simply achieving immediate regularization. What matters, is sustaining the sinus rhythm. The various methods of regularization, using either medical procedures or cardioversion, involve constraints and risks. Investigation of the relapse predicting factor is of great value in evaluating the benefit/risk ratio. For regularization, the absence ultrasound signs of heart disease, an undilated left atrium, recent atrial fibrillation and all forms of heart disease which are curable, albeit surgically, are indicative of success. With regard to prophylaxis, relapses occur more frequently in cases involving mitral valve disease, long-standing atrial fibrillation or a dilated left atrium.

Visualization of myocardial infarction 6 h after injection of 111In-antimyosin antibodies using a blood pool subtraction technique

111In-antimyosin antibodies are capable of visualizing myocardial infarction (MI). Because of slow blood clearance, images are usually recorded 24 or 48 h postinjection. In this pilot study, a blood pool subtraction technique, which makes it possible to visualize MI 6 h postinjection, is validated. Twenty-five patients with proven MI (16 anterior, 9 inferior) were imaged a few minutes, 6 and 24 h after an injection of 111 MBq 111In-labelled antimyosin antibodies. Three planar views are obtained each time. Using software which performs the geometric registration, the grey level normalization and the subtraction of images, the blood pool image (obtained a few minutes postinjection) is subtracted from the 6 h image. The resulting image is the blood pool corrected 6 h image. The 24 h images and the blood pool corrected 6 h images were interpreted blindly and the number of correct, incorrect and impossible MI localizations was counted. The number of correct localizations is 19/25 for the standard 24 h images and 22/25 for the blood pool corrected 6 h images. Then, with this blood pool subtraction method, it is possible to visualize MI 6 h postinjection. This has to be taken into account when discussing the role of antimyosin scintigraphy in the management of patients with MI.

[Massive pulmonary embolism disclosing thrombocytopenia induced by low molecular weight heparin. Therapeutic success of prostacyclin]

The authors report a case of massive pulmonary embolism revealing thrombocytopenia induced by a low molecular weight heparin (LMWH) initially proposed for the treatment of superficial phlebitis. The diagnosis was confirmed by in vitro aggregation tests and a fall in the platelet count when the LMWH was reintroduced. The outcome was clinically, angiographically and hematologically satisfactory in response to in situ treatment with prostaglandin, subsequently replaced by Vitamin K antagonists.

[Prognostic value of exercise angioscintigraphy in coronary disease]

Multivariate survival analysis (MSA) was applied to 97 patients with coronary disease using the Cox model and a stepwise regression procedure. Seventeen variables including data based upon clinical examination, exercise testing (ET), and exercise angioscintigraphy (EAS) as well as coronary arteriography were studied in each patient. During the monitoring period (interval: 1-57 months), 38 patients sustained a cardiac event (recurrence of coronary disease or death). Neither resting left ventricular ejection fraction, nor coronary anatomy were significant prognostic variables. The only two variables identified by MSA were a variable of EAS: corrected ejection fraction at maximum exercise (p less than 0.008), and a variable of ET: maximum heart rate during exercise (p less than 0.03). This study shows that the prognosis of a coronary disease patient can best be assessed by two variables which are both exercise parameters.

[Postoperative hemopericardium compressing the left atrium. Apropos of 8 cases]

The authors report 8 cases of hemopericardium compressing the left atrium occurring at varying intervals after cardiac surgery. This is an unusual anatomical and classically rare site of pericardial effusion. This type of tamponnade has special clinical features, leading to a picture of subacute left ventricular failure, by interference with filling and typical echocardiographic appearances, with special features in two-dimensional mode and, in TM mode, an abnormal anterior movement of the posterior wall of the left atrium, which is studied. CT scan of the thorax, when performed, confirms this highly specific topographic situation. This type of effusion must be managed surgically as quickly as possible, with an anterior approach, either by left thoracotomy or by midline sternotomy.

[Therapeutic value of esophageal stimulation. Factors influencing the results in flutter and atrial tachysystole]

The aim of this prospective study was to identify factors predicting the efficacy of atrial stimulation by esophageal route in 57 nonselected patients between 37 and 88 years of age and admitted for intensive care due to flutter or atrial tachycardia. It was impossible to perform the procedure correctly in 4 patients. The restoration of sinus rhythm was achieved in 28.3% of cases at the end of the procedure and in 47.2% of cases after 24 hours. These results were influenced by the duration of the arrhythmia, the underlying cardiopathy and the diameter of the left atrial, but were not affected by the stimulation parameters.

[Doppler echocardiographic evaluation of the efficacy of fibrinolytic treatment of pulmonary embolism]

The efficacy of the fibrinolytic therapy in pulmonary embolism was studied by Doppler echocardiography: the evolution of the cardiac and angiographic changes could be studied in parallel. Thirty patients with severe pulmonary embolism and vascular obstruction greater than 40% (67.2 +/- 9.9%) were examined prospectively by Doppler echocardiography before and after thrombolysis. The following parameters were studied: systolic pulmonary artery pressure calculated from the jet of tricuspid regurgitation and left and right ventricular diameters for the calculation of the ratio of the ventricular dimensions. All patients underwent Doppler echocardiography and pulmonary angiography immediately after thrombolysis. The average improvement of the percentage vascular obstruction was 37%. The hemodynamic and echocardiographic changes were globally favourable. The pulmonary artery systolic pressure fell from 51 +/- 10 to 33 +/- 6.7 to 25.3 +/- 6.3 mm and the ratio of ventricular dimension from 0.87 +/- 0.3 to 0.60 +/- 0.16 (p less than 0.001). Only 4 patients had pulmonary artery systolic pressures over 40 mmHg after therapy compared with 26 before therapy. However, the hemodynamic and angiographic correlations were poor (r = 0.37; p less than 0.001). In the 6 patients in whom treatment was ineffective according to angiographic criteria (less than 20% improvement of vascular obstruction), the echocardiographic changes were small or absent, the improvement in the ratio of ventricular dimensions being less than 20%. However, a satisfactory correlation was observed between the percentage improvement of the ratio of ventricular dimensions and that of vascular obstruction (r = 0.59; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis and evaluation of mitral endocarditis complicating obstructive cardiomyopathy using cardiac echo-Doppler]

The authors report a case of mitral endocarditis diagnosed by cardiac echo-Doppler and complicating an obstructive cardiomyopathy (OCM) in a 37-year-old woman. Despite the high degree of sub-aortic obstruction and the existence of an apparently severe mitral leak by Doppler analysis, the patient remained totally asymptomatic and the outcome was favourable with appropriate antibiotics. A review of the literature revealed 11 cases of endocarditis in a context of OCM, documented by echocardiography. Echo-Doppler enables precise evaluation of this grave and often poorly tolerated complication of OCM.

[Malignant histiocytofibroma of the heart simulating myxoma of the left atrium]

The authors report a case of malignant fibrous histiocytoma of the left atrium which was excised but rapidly recurred in a 47-year-old woman. Clinical examination, echocardiography and the absence of biochemical abnormalities were in favour of the diagnosis of left atrial myxoma. This report illustrates the clinical similarity between myxoma and sarcoma of the left atrium. Very careful anatomopathological examination of multiple sections of the tumour are necessary to distinguish it from benign tumours, especially myxomas.

[Iatrogenic arteriovenous fistula between the internal mammary artery and the innominate venous trunk. Contribution of digital arteriography in the positive and anatomic diagnosis]

The authors report the case of an arterio-venous fistula between the internal mammary artery and the trunk of the innominate vein following puncture of the internal jugular. The clinical signs of this unusual complication led the authors to list the differential diagnoses which should be considered and to draw attention to the importance of digitalized angiography in anatomical diagnosis.

[Differential analysis of mitral and tricuspid regurgitation by continuous Doppler]

The following parameters have been measured by continuous Doppler in 40 patients with both mitral failure (MF) and tricuspid failure (TF): effusion time (ET), peak time (PT), maximum effusion speed (S. max), maximum anterograde speed (S. ant), taking into account the cardiac rate and the ejection fraction. Only the S. max. and the S. ant. are significantly different and enable the determination of the effusion origin with a percentage error of about 4%. When a straight line is drawn to joint 3.7 m/s on the ordinate (S. ant) and 5 m/s on the abcissa (S. max), the TF lie below the line and the MF above it. The selection of the sub-groups with low ejection fraction (less or equal to 30%) or with arterial pulmonary hypertension (S. max MF higher or equal to 3 m/s) does not modify the precision of the discrimination. The graph suggested seems therefore to be a rapid and reliable means of characterizing TF in order to assess the arterial pulmonary hypertension of dilated hypokinetic cardiomyopathies.

[Comparative study of cibenzoline and flecainide administered via an intravenous route in reducing auricular arrhythmia]

The efficacy of intravenous flecainide and cibenzoline acetate in the reduction of atrial rhythm disorders was compared in two groups of 30 patients. These arrhythmias are divided in 31 atrial fibrillation, 11 tachy-systoles, 18 atrial flutters. Parenteral administration of the anti-arrhythmic drug over a 24 hour-period is preceded by a bolus injection of 1.5 mg/kg of flecainide acetate for group I, and a bolus of 1 mg/kg of cibenzoline for group II. The overall efficacy of the two molecules is comparable (53%) as well as the reduction of the atrial fibrillations (65% vs 57%). Flecainide acetate seems more effective in treating effectively atrial tachycardias (66.6% vs 40%), and cibenzoline is more effective in the treatment of atrial flutters (54% vs 14%). The functional, electrical and haemodynamic tolerance has always been good in both group, except in 2 patients, because of the indirect pro-arrhythmic effect of cibenzoline. We are concluding that the efficacy of both molecules is satisfactory and we advocate their use, as first intention, in recent and idiopathic atrial fibrillation; it seems that cibenzoline is more effective on ischemic cardiopathies and flecainide acetate is more effective on valvular cardiopathies. Nevertheless, the possible indirect pro-arrhythmic effect, sometimes poorly tolerated in the first minutes following administration of the bolus, only on organized atrial rhythm disorder, leads us to advocate the prescription of these two drugs when attempts of transesophageal or endocardiac atrial stimulation have failed.

[Natural course of type III traumatic chronic dissection in a patient with Marfan's syndrome]

Description of a traumatic dissection of the descending thoracic aorta, occurring in a female patient with Marfan's syndrome, the chronic course of which over more than three years was complicated by retrograde extension to the ascending thoracic aorta, resulting in death by massive aortic insufficiency and pleuro-pericardial effusion. Advantages of clinical and sonocardiographic monitoring of chronic dissections.

[Ultrasonic diagnosis of biventricular thrombus during the acute phase of myocardial infarction]

The occurrence of a left ventricular thrombus is a classic complication of acute myocardial infarction. On the contrary, this is much less frequent in the right ventricle. The authors report the case of a patient presenting a biventricular thrombus resulting as a complication of an anterior myocardial infarction, diagnosed by bidimensional ultrasonography. The course is characterized by the occurrence of a cerebral vascular accident. The sonogram following this neurological accident shows that the left ventricular thrombus has disappeared, confirming its migration. On the contrary, the right ventricular thrombus regressed under appropriate heparin treatment, without any embolic complication.

[Diagnostic, prognostic and therapeutic value of Doppler echocardiography in pulmonary embolism. Apropos of 41 cases]

In 41 patients with acute or recent pulmonary embolus (PE), a prospective study was conducted with cardiac Doppler sonography (CDS). The test is performed first in all patients, then immediately following a treatment fibrinolytics in 10 of them. The PE is confirmed by pulmonary angiography in 39 patients and embolectomy for the 2 patients who presented a mobile thrombus in the right atrium. A tricuspid insufficiency (TI) is almost always recorded by continuous Doppler: the systolic pulmonary artery pressure (sPAP) is calculated from the maximum velocity of the regurgitating tricuspid flow, using Bernouilli's equation. The correlation between Doppler sPAP and sPAP obtained by catheterization is: r = 0.95 (n = 34; p less than 0.001). A severe pulmonary hypertension, corresponding to a TI exceeding 3.5 m/s is related to a pulmonary migration occurring on a pathological heart. There is a satisfactory relationship between the elevation of the Doppler sPAP and the degree of pulmonary obstruction in the "Pe on healthy heart" population: r = 0.6 (n = 29; p less than 0.001). The dilated right ventricle observed on the sonogram (RV) is proportional to the severity of the angiographic image: correlation between the RV/LV ratio and the percentage of vascular obstruction is r = 0.73 (n = 27; p less than 0.001). The drop in the sPAP and the regression of the symptoms of pulmonary heart noted on CDS after fibrinolysis, correspond to a significant improvement of the pulmonary perfusion. The CDS seems to be absolutely necessary in PE because of the major and reliable informations it provides.

[Acute dysfunction of mitral bioprosthesis: Doppler expression of a musical holosystolic murmur. Apropos of 2 cases]

Two women who had been fitted with a porcine mitral valve seven years previously suddenly developed acute dysfunction of the bioprosthesis with regurgitation. In both patients physical examination revealed an intense, vibrating, musical holosystolic murmur sounding like a "goose cry" and located at the apex. Pulsed doppler showed major, jet-like, central orothetic mitral regurgitation. A harmonic graph was recorded when the doppler window was positioned upstream of the porcine valve leaflets. The finding of such a doppler signal in this clinical context suggests tearing or perforation of one cuspid and rules out the possibility of bioprosthesis degeneration.

[Congenital ventricular septal defect with late detection. Apropos of a case in an adult]

The authors report the case of a congenital interventricular communication discovered in a 75 year-old female patient. The shunt was identified on the cardiac Doppler and confirmed by catheterization. It was a type IIa interventricular communication which decompensated in the course of a pulmonary embolism. This case points out how rare is the diagnosis of congenital interventricular communication made during adulthood, and emphasizes the advantage of the Doppler in the diagnosis of ventricular shunts.

[Postoperative hemopericardium compressing the left atrium. Apropos of a case]

We report a case of tamponade due to an effusion of blood which had occurred two weeks after an aorto-coronary bypass and was unusually located behind the left atrium. The effusion, with severe clinical symptoms, was diagnosed by echocardiography and computerized tomography of the chest. These examinations provided an accurate anatomical diagnosis on which the approach route of the emergency operation was based.

[Comparative study of pulsed and continuous Doppler in the quantification of aortic insufficiency]

31 patients whose mean age was 61 +/- 29 yrs. presenting with aortic regurgitation (AR) benefited from cardiac catheterization which was preceded by Doppler ultrasound examination in a prospective study to compare the diagnostic contributions made by continuous vs pulsed wave techniques respectively in the quantitative assessment of AR, with reference to semi-quantitative angiographic evaluation. Pulsed Doppler analysis involves mapping of the left ventricle in two projections as well as the investigation of blood flow in the aortic isthmus using a suprasternal approach. Collection of continuous wave signals from the cardiac apex makes it possible to measure circulatory deceleration and the half-time of decrease in signal velocity and the protodiastolic pressure gradient. Our results corroborate the reliability of data obtained using continuous-wave Doppler technique in finding significant correlations for each parameter respectively: r' = 0.88 (p less than 0.001); r' = -0.81 (p less than 0.001); r' = -0.75 (p less than 0.001). Values determined by pulsed wave Doppler mapping of the left ventricle appear to be less satisfactory but are significant: r' = 0.68 (p less than 0.001) while measurement of end-diastolic blood flow recorded in the isthmus of the aorta is more highly correlated: r' = 0.84 (p less than 0.01), with the main disadvantage being its limited applicability to a small number of our patients (48%). We thus concluded that continuous-wave Doppler ultrasound is a better technique in the quantitative evaluation of AR, while recalling the essential additional value of pulsed-wave Doppler technique to localize the leakage and of ultrasound to assess its impact on the left ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Validation of a method for measuring the area of aortic stenosis using only continuous Doppler. Value for the surveillance of transluminal aortic valvuloplasties]

Forty patients with aortic valve stenosis underwent continuous wave doppler-echocardiographic exploration followed by catheterization within 24 hours on average. Three methods of aortic functional area calculation, based on the continuity equation principle, were tried and compared with the haemodynamic data. The results of the reference equation (continuity through the whole systole) gave a correlation coefficient r = 0.77 with a standard error (SE) of 0.17 cm2. The continuity equation using only maximum velocity values was less satisfactory: r = 0.69; SE = 0.19 cm2. The simplified equation with an arbitrary 2 cm subaortic diameter and a subaortic velocity obtained by continuous wave doppler recording yielded results that were very similar to those of the reference equation: r = 0.78; SE = 0.16 cm2. It is suggested that this third equation should be used in the follow-up of transluminal aortic valvuloplasties, since its calculation is based only on aortic velocity, which reflects the degree of stenosis, and subaortic velocity, which indirectly reflects left ventricular function.

[Diagnostic and prognostic value of continuous Doppler in pulmonary embolism]

A prospective study of 18 patients admitted to hospital for acute pulmonary embolism confirmed the reliability of continuous wave cardiac doppler as a non-invasive method of evaluating systolic pulmonary artery pressures. These pressures were calculated by applying the simplified Bernoulli equation to the maximal velocity of regurgitant tricuspid flow and compared with the results of cardiac catheterisation and angiography, the percentage of vascular obstruction being assessed using Miller's index. The correlations between the two methods were good, r = 0.96; p less than 0.001, with a standard error of +/- 5.2 mmHg. The correlations between the velocity of tricuspid flow and the percentage of obstruction were less significant (r = 0.65; p less than 0.005) but improved when patients with pre-existing cardiopulmonary disease were excluded. This technique of non-invasive assessment of haemodynamic parameters also helps in evaluating the underlying pathology; tricuspid regurgitation with velocities greater than 3.5 m/s is associated with pre-existing chronic cor pulmonale, information of prognostic interest which would guide therapeutic management.

[Role of clinical manifestations, the exercise test and exertion angioscintigraphy in the diagnosis of coronary disease. A multivariate study]

Data of clinical examination, exercise electrocardiography and stress radionuclide angiography in 102 patients referred for assessment of chest pain was included in a logistic regression to optimise the diagnosis of coronary artery disease with coronary angiography as the reference investigation. None of the patients had other cardiac problems nor previous myocardial infarction. In the absence of symptoms exercise testing was continued until at least 80 p. 100 of the theoretical maximal heart rate was attained. Each patient was characterised by the value of the logistic function or probability of coronary artery disease. A threshold value corresponding to 80 p. 100 sensitivity was determined by the technique of ROC graphs. The significant variables were: a clinical variable--the type of chest pain as assessed by the clinical history; two radionuclide angiographic variables--the ejection fraction at peak effort and the corrected variation of ejection fraction between rest and stress, that is not taking into account possible decreases at the last increment of exercise. Coronary patients can be identified with an 80 p. 100 sensitivity and 77 p. 100 specificity on these criteria. This specificity is greater than that obtained by clinical examination and exercise electrocardiography alone (65 p. 100). Stress radionuclide angiography may therefore reduce the number of unnecessary coronary angiographies.

[Floating thrombus of the right atrium in acute pulmonary embolism. Clinical, echocardiographic aspects and therapeutic sequelae]

The performance of a systematic sonocardiography in all our patients hospitalized since January 1985 for pulmonary embolism, has enabled to discover five cases of floating thrombus of the right atrium. Three patients presented an abnormal auscultation, with one of them presenting a tricuspid wedge syndrome. On the sonogram, the aspect of the thrombus, "coil or ball-shaped", floating in the atrial cavity, sometimes prolapsed through the tricuspid valve, associated with the signs of a pulmonary heart, enables to rule out other right intraatrial masses. Pulmonary angiography seems contra-indicated because of the risk of embolus of this thrombus, the migration of which may be fatal. Embolectomy, under extra-corporeal circulation (heart-lung pump) with examination of the right cavities appears to be the treatment of choice.

[Quantification of chronic aortic insufficiency. Comparison between Doppler ultrasonic diagnosis and the radiocardiogram]

The objective of this study is to quantify aortic insufficiency by comparing pulsated Doppler ultrasonography and radiocardiography used as reference test. Since february 1986, 23 patients were tested with both techniques within 15 days. The Doppler ultrasonography enabled to quantify aortic insufficiency in 4 stages by semi-quantitative mapping of the regurgitation flow of the left ventricle (LV). Radiocardiography (RCG) has enabled the determination of the regurgitation fraction (RF), for each patient. A mean RF was calculated on RCG, for each Doppler stage. The FR difference between each Doppler stage is significant, especially between minimal and severe aortic insufficiency. RCG is the first stage of an isotopic examination, at rest and during stress; it may be followed by Doppler ultrasonography in monitoring patients with aortic insufficiency.

[Subvalvular aortic stenosis discovered after surgical repair of an atrioventricular canal in the adult. Apropos of a case]

The case of an adult female patient in whom subaortic stenosis was discovered 9 months after surgical correction of a partial atrioventricular canal is reported. The authors describe the difficulties encountered in the pre-operative diagnosis of this uncommon association and the paraclinical methods now available, notably echocardiography, that may help overcome these difficulties.

Diagnostic value of stress radionuclide angiography in coronary artery disease: a comparison of different interpretation criteria

In order to compare different criteria in the interpretation of stress radionuclide angiography (SRNA) 96 patients with suspected coronary artery disease (CAD) were investigated by both SRNA and coronary arteriography. The result of coronary arteriography was taken as the gold standard for the diagnosis of CAD. Left ventricular ejection fraction (LVEF) was measured at each step of the stress study using the equilibrium radionuclide technique. The diagnostic value of eight interpretation criteria based on the evolution of global LVEF during stress were compared with each other, using the ROC technique. The best diagnostic criterion proved to be the normalized increase of LVEF proposed by Goris. The most commonly used criteria, LVEF increase and LVEF measured at maximal exercise, were not optimal. In the whole population of patients, the best criterion had a sensitivity of 85% for a specificity of 80% and a specificity of 83% for a sensitivity of 80%. In the population, following exclusion of patients with preceding myocardial infarction, the specificity was 74% for a sensitivity of 80% and a sensitivity of 74% for a specificity of 80%. Thus, the choice of interpretation criteria is very important in order to optimize the sensitivity and specificity of this diagnostic test.

[Evaluation of pulmonary systolic arterial pressures by continuous Doppler in tricuspid regurgitation in adults. Apropos of 43 cases]

Forty-three hospital patients with tricuspid regurgitation were prospectively explored by continuous wave Doppler ultrasound to determine their pulmonary systolic arterial pressure. In the absence of pathology of the pulmonary orifice this value corresponds to the sum of the right atrioventricular systolic gradient calculated by Bernoulli's equation DP = 4V2 from the tricuspid regurgitation and the right atrial pressure evaluated by clinical examination. The values obtained are compared with the results of right heart catheterization. Our study showed good correlation (r = 0.90) with a standard error of 8.2 mmHg, the main source of effort being the clinical quantification of right atrial pressure. These results confirm that pulmonary systolic arterial pressure can reliably be measured by this method in the presence of tricuspid regurgitation. The method is of considerable interest in permanent pulmonary hypertension or in emergencies.

[Comparison of the effects of bepridil and diltiazem in Prinzmetal's angina. Crossed, randomized, double-blind study. Apropos of 14 cases]

The efficacy of bepridil was compared with that of diltiazem in treatment of Prinzmetal's angina, in a crossed, randomized double-blind study of 14 observations using repeated Holter recordings (a total of 9 for each patient). Clinical and electrical monitoring showed that the efficacy of bepridil is comparable to that of diltiazem in treatment of spastic angina.

A new method for objective evaluation of cardiac parametric images

A new method for analyzing cardiac parametric images is introduced. Its original feature is the representation of local heart motion in a polar coordinate plane which makes the integration of the information contained in three parametric images possible. These images are calculated using first harmonic Fourier filtering and are the maximum volume image, the local ejection fraction image, and the phase image. The last two parametric images are considered as the complex ejection fraction parametric image which is described by a 2D distribution in the complex plane. This method is a generalized 2D version of the well-known phase histogram method. By segmenting the complex plane in which this representation is made, four indexes are defined called the index of hypokinesia, the index of asynergy, the mean phase shift in asynergic regions, and the mean ejection fraction in asynergic regions. The values of those indexes are used to assess the degree and extent of regional wall motion abnormalities. An automated classification as normal, hypokinetic, akinetic, slightly dyskinetic, and strongly dyskinetic made on the basis of the values of those indexes has been compared with a visual classification made by three observers in 219 studies. ROC curves show a good agreement between the automated and visual methods. This new method provides an efficient means of automatically classifying cardiac studies.

[Study of thesaurismosis induced by perhexiline maleate. Confirmation of experimental data]

Perhexiline maleate is an amphiphilic molecule. Along with many other drugs it is responsible for experimental and, in some instances, clinical lipidoses. Sphingomyelinase deficiency has been evidenced in cell cultures incubated with perhexiline maleate. We describe the occurrence of a similar defect in a patient. The disturbances in the phospholipid turnover which are responsible for the thesaurismosis may originate in the sphingomyelinase deficiency.

[Predictive value of the exercise test for multivessel disease after initial myocardial infarction]

The extent of coronary artery disease after primary myocardial infarction is an important prognostic factor. The predictive value of exercise electrocardiography for multivessel disease was assessed by comparison with coronary angiography in a series of 100 patients. In the group of patients with primary anterior infarction (n = 48), 37.5% had positive exercise ECGs. Coronary angiography showed 62.5% single vessel disease. In multivessel disease, the sensitivity of exercise ECG was 78% and specificity 86%. The predictive value of a positive test was 78% and, for a negative test, 86%. In primary inferior infarction (n = 52), positive exercise ECGs were recorded in 48% of cases. Coronary angiography showed 48% multivessel disease. In multivessel disease, sensitivity of exercise ECG was 92% ans specificity 93%. The predictive value of a positive test was 92% and of a negative test, 93%. Therefore, exercise ECG gives a more precise prediction of the extent of coronary artery disease after primary inferior infarction than after primary anterior infarction. However, it is not an ideal guide for the choice of patient for coronary angiography because of its poor predictive value in cases of anterior infarction, and because of the high incidence of multivessel disease in patients with primary inferior infarcts. Nevertheless, it is of great prognostic value with regards to the eventual course of the coronary disease.

Technique for tricuspid annuloplasty with a flexible linear reducer: medium-term results

The surgical treatment for tricuspid incompetence requires a choice between reconstruction or replacement with a prosthetic valve. The conservative approach offers many advantages in functional tricuspid incompetence. Our technique for annuloplasty utilizes a flexible linear reducer (FLR) to support a selective reduction of the distended portion of the anulus. The insertion of the septal leaflet is always left free, and physiological flexibility of the tricuspid anulus is assured. The repaired valve is sturdy because of the prosthetic support, and inserting the FLR is simple and poses no risk to the His bundle. The medium-term results (mean follow-up 10 months) in 20 consecutive patients (all with a complete postoperative reinvestigation) are satisfactory. Because this procedure is simple and harmless, it frequently can be applied for direct correction of functional tricuspid incompetence during polyvalvular operation.

[Cardiac manifestations of pheochromocytoma. Anatomo-clinical study]

Cardiomyopathy induced by catecholamines, first demonstrated in the animal is also observed in clinical medecine either after infusion by vasopressor drugs or during the course of pheochromocytoma. The clinical presentation is varied and may often deceive: acute coronary insufficiency, arrhythmia, heart failure, and, above all, cardiogemic shock. The authors emphasise the importance of considering the diagnosis of "adrenergic myocarditis" in such situations as well as in cases of pheochromocytoma, for which the only cure is ablation of the tumour.

[Treatment of functional tricuspid insufficiency by a valvuloplasty with a flexible linear reducer]

Valvuloplasty with preservation of the valvular apparatus is the treatment of choice in functional tricuspid incompetence (FTI). A new method of valvuloplasty has been developed using a flexible linear reducer (FLR); its insertion is simple and without risk to the Bundle of His. It is made of sections of elastomere covering a dacron core. The principle of the FLR is reduction of the tricuspid annulus leaving the septal leaflet free. It is a simple method which allows individual variations in the zone reduced (usually involving the anterior and inferior leaflets) and in the size of the reduction at each point. The excellent results at medium term in 20 patients with tricuspid FLR lead us to recommend widening the surgical indications for correction of FTI especially in cases where signs of right ventricular failure have been observed.

[Echocardiographic aspects of the atrio-ventricular canal]

The authors report their experience of echocardiography in cases of atrio-ventricular canal in the light of 9 cases which were studied by time-movement and 2-dimensional echography. In cases if ostium primum, the essential findings are: diastolic juxtaposition of the mitral valve to the left side of the septum, its multiple-echo appearance during systole, and the abnormal movement of the ventricular septum. In cases of complete atrio-ventricular canal, two main types are found. In the first, the echos of the atrio-ventricular valve are confused with those of the interventricular septum during diastole; in diastole, the septum disappears, one valve moves anteriorly into the right ventricle, and the other moves posteriorly into the left ventricle. In the second type, the appearances are those of a single valve which is situated within the left ventricle during systole, and which 'crosses' the interventricular septum to gain the right ventricle during diastole. The interpretation of these findings is difficult. It becomes clearer, however, when it is realised that the plane of incidence of the ultrasonic waves is not perpendicular to the plane of movement of the atrio-ventricular valve. The authors' conculsion is that echocardiography is a method of diagnosings atrio-ventricular canal defects, bud does not allow the anatomical type to be defined.

[Femoral nerve paralysis complicating anticoagulant treatments. A propos of 3 cases]

The authors report 3 new cases of femoral nerve paralysis complicating anticoagulant treatment. The first sign was pain, the neurological signs occurred later and the patient usually recovered but recovery was sometimes incomplete. The pathogenesis is not clear : a muscle hematoma, ischemia of the nerve trunk, and intraneural hemorrhage are the commonest theories.