[Isolated and asymptomatic Brugada syndrome. A case report]

The case report of a 32-year-old man with a Brugada syndrome is presented. He was asymptomatic and without familial history of sudden death or syncope. Diagnosis criteria for Brugada syndrome were 1--a pattern of right bundle branch block and ST-segment elevation in leads V1 and V2 on the ECG, 2--no cardiac structural anomalies. Symptomatic patients with this electrical anomaly are at high risk of sudden death and need an automatic implantable defibrillator. The outcome and the treatment of asymptomatic patients are a matter of debate and are discussed in this report.

Left ventricular volume analysis for the detection of coronary artery disease during dobutamine stress echocardiography in patients undergoing vascular surgery

AIMS

The purpose of the study was to prospectively evaluate the effectiveness of left ventricular volume changes analysis as compared to wall motion assessment for detecting coronary artery disease during dobutamine stress echocardiography in patients undergoing elective vascular surgery.

METHODS AND RESULTS

Left ventricular volumes, measured by using the ellipsoid biplane method combining the apical four- and two-chamber echocardiographic views, and classical wall motion score were determined at rest and peak stress (dobutamine infusion 5-40 microg/kg/min+/- atropine 0.25-1mg) in 68 consecutive patients. A positive test was defined as a decrease of less than 15% in left ventricular end-diastolic or end-systolic volume at peak stress for volume analysis and as an increase in score between rest and peak stress in one or more segments for wall motion assessment. Stress test was not analysable in five patients. Coronary angiography revealed significant coronary artery disease (coronary stenosis >or=70%) in 28/63 (44%) patients: one-vessel in 15, two- or three-vessel disease in 13. Overall sensitivity and specificity for coronary artery disease detection were 56% and 97% with left ventricular volume analysis, as compared to 64% and 89% with wall motion assessment. For patients with two- or three-vessel disease, sensitivity and specificity of volume analysis reached 92%.

CONCLUSION

The present data suggest that left ventricular volume change analysis during dobutamine stress echocardiography could be a reliable method for the detection of extensive coronary artery disease for patients undergoing vascular surgery.

[Evaluation of echo-guided pericardiocentesis in cardiac tamponade]

Between April 1982 and December 1995, 78 consecutive patients with an average age of 57 +/- 13 years underwent echo-guided pericardiocentesis in the intensive care unit for poorly tolerated pericardial effusions. The patients were admitted to the cardiology departments of Ambroise-Paré Hospital at Boulogne (n = 44). Gilles-de-Corbeil Hospital at Corbeil-Essonnes (n = 31) and Val-de-Grâce Hospital in Paris (n = 3). The underlying aetiologies were malignant disease (n = 31), idiopathic (n = 13), post-surgery (n = 7), infection (n = 7), autoimmune (n = 6), post-radiotherapy (n = 6), post-myocardial infarction (n = 3), chronic renal failure (n = 3) and coagulation defects (n = 2). Pericardial puncture was undertaken by the subxiphoid (n = 77) or left parasternal (n = 1) approaches under guidance of echocardiography. Intra-pericardial contrast was used to verify the position of the catheter. The average volume of liquid drained was 580 +/- 390 mL. After pericardiocentesis, continuous drainage was continued in 17 patients for an average duration of 63 +/- 29 hours. The total average volume was 750 +/- 330 mL. The major complications were a) three deaths during the puncture, not caused by the procedure after post-mortem study, b) ten right ventricular punctures with no consequences in 9 cases, c) two cases of shock, one of which was due to a pre-existing septicaemia of pulmonary origin, d) two non-sustained ventricular arrhythmias. The minor incidents were six vasovagal syndromes during the procedure and four paroxysmal supraventricular arrhythmias. Emergency surgical drainage was required (n = 3) for a failed procedure and late surgical drainage (n = 12) for persistence or recurrence of the effusion. No surgical drainage was required in the 17 patients placed under continuous aspiration. Echo-guided pericardiocentesis is a simple procedure and provides rapid haemodynamic relief in subjects generally in serious condition. Continuous aspiration may help avoid the need for surgical drainage for persistence or recurrence of the effusion.

Acute myocardial infarction in a patient with severe aortic stenosis and normal coronary arteries

We report a case of acute myocardial infarction occurring in a patient with severe aortic stenosis and left ventricular hypertrophy. A coronary angiogram performed during the acute phase of evolving myocardial infarction excluded coronary obstruction as the cause of acute myocardial infarction in this patient.

Oral enoximone as a substitute for intravenous catecholamine support in end-stage congestive heart failure

We performed a double-blind, placebo-controlled study to determine whether oral enoximone would aid weaning dobutamine-dependent patients. Twenty-four patients 64 +/- 10 years, with an echocardiographic ejection fraction of 0.20 +/- 0.06, and receiving maximal therapy were studied. After failure of dobutamine weaning, a dobutamine infusion was set up at 10 micrograms.kg-1.min-1 for 48 h. Oral enoximone (100 mg t.i.d.) or placebo was added from D0 for the next 28 days, while the dobutamine dosage was progressively decreased after D4 and eventually stopped at D7. The patients were then followed-up for 21 days (i.e. until enoximone administration had continued for 28 days). In the placebo group, two patients suffered a relapse of congestive heart failure (CHF) before D4, six patients withdrew during dobutamine tapering (five with a relapse of CHF and one with septic shock) and two during follow-up (one with a relapse of CHF and one with sustained ventricular tachycardia). In the enoximone group, three patients withdrew during dobutamine tapering (two with a relapse of CHF, one with a cutaneous rash). Four patients on placebo and nine receiving enoximone could be weaned from dobutamine, P < 0.05. Echocardiographic LV ejection fraction significantly increased and Doppler-derived indexes of systolic function tended to increase when enoximone but not placebo was associated with dobutamine. Oral enoximone might be helpful in weaning patients with end-stage congestive heart failure from i.v. dobutamine.

[Simultaneous measurement of systolic pulmonary artery pressure by catheterization and contrast enhancement doppler echocardiography]

The aim of this study was to assess the value of echocardiographic contrast in measuring systolic pulmonary artery pressures. Thirty-four patients with an average age of 61 +/- 15 years undergoing right heart catheterisation had a simultaneous measurement of systolic pulmonary artery pressures by catheter and colour-coded Doppler echocardiography under basal conditions and after injection of 5% dextrose agitated with 1 cm3 of air to form microcavitations. The Doppler echocardiographic measurements were performed after withdrawal of the catheter into the inferior vena cava before and after injection of contrast. Patients were divided into two groups according to the pulmonary artery pressures at catheterisation: Group I, comprising 11 patients with systolic pulmonary artery pressures of less than 35 mmHg; Group II, comprising 23 patients with systolic pulmonary artery pressures of over 35 mmHg; The injection of contrast significantly increased the number of patients in whom systolic pulmonary artery pressures could be calculated from the Doppler signal of tricuspid regurgitation (TR) in Group I (control: 18%; contrast: 100%, p < 0.01) and Group II (control: 65%; contrast: 96%, p < 0.05). There was a close correlation between the catheter and Doppler measurements of the trans-tricuspid valve pressure gradients before and after injection of contrast in Group I (n = 11, r = 0.85, p = 0.001, with an estimated standard error (ESE) = 3.8 mmHg) and in Group II (control: n = 15, r = 0.89, p = 0.001, ESE = 10.5 mmHg, and after contrast: n = 22, .r = 0.90, p = 0.001, ESE = 7.95 mmHg) with the catheter in the right ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler echocardiographic evaluation of vasodilator treatments in patients with cardiac insufficiency. Contribution to the combination of isosorbide dinitrate and captopril]

Hemodynamic evaluation of a vasodilator drug is a difficult exercise in which Doppler echocardiography can be a useful tool. We studied the hemodynamic effect of isosorbide dinitrate (ISDN) by Doppler echocardiography in 7 patients with severe cardiac failure despite prolonged therapy with usually effective doses of captopril. The patients were evaluated before (H0) and 24 hours after treatment by ISDN (120 mg/24 hr) (H24) and 10 minutes after sublingual 0.75 mg of trinitrin (H24 + T). M mode echocardiography did not show any significant changes in chamber dimension as reported after vasodilator therapy in patients without cardiac dilation: in patients with severe left ventricular dilatation a reduction in LV filling pressures causes little if any changes in fractional shortening and ventricular dimensions. Two-dimensional echocardiography showed a reduction in end systolic volume and an increase in ejection fraction, emphasizing the superiority of this technique in cases of abnormal left ventricular function and the sensitivity of indices of systolic function to changes in afterload in these patients. Cardiac output measured by Doppler increased during the study. The maximal acceleration did not change significantly and pulmonary artery pressures were stable after administration of nitrates. ISDN caused a marked change in diastolic mitral flow patterns for which there are several explanations: an effect of ISDN on relaxation or LV compliance or on the conditions of LV filling or on both factors together. The presence of mitral regurgitation and/or atrial arrhythmia prevents the use of Doppler indices for analysis of diastolic LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left ventricular remodeling and ischemic heart diseases. Therapeutic possibilities]

Left ventricular modeling after myocardial infarction may be modified in three ways: firstly, by limiting the infarct size; secondly, by administering ACE inhibitors: these drugs limit infarct expansion and ventricular dilatation. They reduce the prevalence of secondary left ventricular failure and, in the animal, improve the prognosis. Glyceryl trinitrate also appears to be effective. The third therapeutic option is maintaining the patency of the artery responsible for the infarction, which has a beneficial effect on ventricular remodeling. The respective therapeutic indications of these three options are still a matter of discussion.

[Cystic dystrophy on aberrant pancreas. Contribution of ultrasound-endoscopy]

Cystic dystrophy of aberrant pancreatic tissue without chronic pancreatitis is a rare disease described by Potet and Duclert in 1970. Clinical diagnosis is possible by endoscopy and intraluminalsonography; we report the first case diagnosed by intraluminalsonography.