The impact of conservation on the status of the world's vertebrates

Using data for 25,780 species categorized on the International Union for Conservation of Nature Red List, we present an assessment of the status of the world's vertebrates. One-fifth of species are classified as Threatened, and we show that this figure is increasing: On average, 52 species of mammals, birds, and amphibians move one category closer to extinction each year. However, this overall pattern conceals the impact of conservation successes, and we show that the rate of deterioration would have been at least one-fifth again as much in the absence of these. Nonetheless, current conservation efforts remain insufficient to offset the main drivers of biodiversity loss in these groups: agricultural expansion, logging, overexploitation, and invasive alien species.

[Acute pericarditis: results of a survey of treatment practices of cardiologists]

Benign acute pericarditis is a common disorder. Although, at first glance, its management appears well defined, the guidelines issued by professional societies with respect to optimal treatment and length of its administration remain vague.

METHODS

a brief, anonymous questionnaire probing into treatment practices was sent in April 2005 to all cardiologists of Brittany.

RESULTS

we collected 164 analyzable questionnaires out of 248 submitted (66%). The initial investigations in presence of acute pericarditis included an electrocardiogram in 100% of cases, an echocardiogram in 95%, and screening biochemistry in 93% of cases. Systematic hospitalisation was advised by only 24% of cardiologists. Aspirin was prescribed as first choice treatment in 92.5% of cases. Duration of treatment recommendations varied widely, from <5 days by 2.5%, between 5 and 10 days by 25.5%, 11 and 15 days by 23.0%, 16 to 21 days by 35.3%, and for >21 days by 14% of cardiologists. Hospital-based cardiologists were more likely to systematically hospitalise their patients than outpatient practice-based physicians (79.5% versus 5.1%; p<0.001) as well as to order an initial biochemical screening tests (100% versus 81.4%, p<0.01). Cardiologists <42 years of age recommended significantly fewer hospitalisations than older physicians (6.8% versus 36.4%: p<0.001).

CONCLUSIONS

the management of acute, benign pericarditis was limited nearly exclusively to the prescription of aspirin. Duration of treatment varied widely. These observations are concordant with data published in the literature (where the recommended duration of treatment is systematically missing).

Assessment of coronary artery stents by 16 slice computed tomography

OBJECTIVE

To analyse coronary stents with multislice spiral computed tomography (MSCT) in comparison with coronary angiography.

PATIENTS AND METHODS

310 patients referred for conventional coronary angiography underwent MSCT on the next day (16 x 0.75 mm cross section, 420 ms rotation, 110 ml contrast agent intravenously at 4 ml/s). Two independent blinded reviewers analysed the MSCT.

RESULTS

143 patients had previous stenting (232 stents) and 190 (82%) of the 232 stents were detected. Intrastent lumen was interpretable in 126 (64%) of the detected stents. Lumen interpretability depended on stent diameter: for stent diameter > 3 mm, 81% of lumens were interpretable, as against 51% with < or = 3 mm stent diameter (p < 0.001). Restenosis detection likewise depended on stent diameter: with small stents (< or = 3 mm), sensitivity and specificity of MSCT were 54% and 100%, respectively; positive and negative predictive values were 100% and 94%. For stents with > 3 mm diameter, corresponding values were 86%, 100%, 100%, and 99%.

CONCLUSION

16 slice MSCT allows analysis of in-stent lumen in about half of all stented angioplasties. It performs better when stent diameter is more than 3 mm and may offer a non-invasive alternative to conventional coronary angiography for monitoring stented coronary arteries. Technical progress may improve interpretability and hence increase the yield of MSCT in this application.

[New developments in the management of syncope]

The management of patients presenting with syncope has without doubt evolved in a spectacular manner over recent years. This evolution is the result of intense clinical research activity led jointly by several teams in the world, mainly in Europe. It has materialised with the publication, at the European Cardiology Society's instigation, of recommendations which have highlighted our current knowledge and ignorance. This article does not presume to review every published development in recent years, but simply to alert or remind the reader in the limited space available about the innovations which seem the most important, starting with the unanimously accepted definition of syncope, without which any discussion of this symptom is futile.

[Evaluation of postoperative mortality and quality of life of patients over 75 years of age after valve replacement for aortic stenosis. Report of 110 cases]

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.

Short and long-term single-centre experience with an S-shaped unipolar lead for left ventricular pacing

Left ventricular-based pacing is an established method for treatment of congestive heart failure in patients with ventricular dyssynchrony. The transvenous epicardial approach is the method of choice to pace the left ventricle.

AIMS

To evaluate short and long-term stability and pacing and sensing performance of an S-shaped non-steroid unipolar lead.

METHODS

Forty-eight procedures were performed in 43 consecutive patients (mean age: 70+/-8 years, 32 males) with severe congestive heart failure. The left ventricular lead was placed into a coronary sinus tributary. Pacing and sensing thresholds and pacing impedance were measured at implant, 1 and 6 months.

RESULTS

The mean procedure time was 90.0+/-35.5 min. Pacing thresholds at implant, 1 and 6 months were 1.1+/-0.8 V, 1.9+/-1.3 V and 1.9+/-1.5 V respectively. In 7 patients, lead implantation was unsuccessful. One of them had a successful second attempt. Lead revision was performed in 5 patients for loss of capture.

CONCLUSION

The S-shaped unipolar lead evaluated in this study provides stable long-term position and pacing thresholds. Recent improvement of this S-shaped lead model will hopefully reduce the rate of implantation failures and acute dislodgements.

Stent implantation for the treatment of superior vena cava syndrome related to pacemaker leads

This is a case-report of two patients with superior vena cava syndrome related to pacemaker leads. Both patients were treated successfully using intravenous stenting.

Automatic P-wave analysis of patients prone to atrial fibrillation

A method is presented for automatic analysis of the P-wave, based on lead II of a 12-lead standard ECG, in resting conditions during a routine examination for the detection of patients prone to atrial fibrillation (AF), one of the most prevalent arrhythmias. First, the P-wave was delineated, and this was achieved in two steps: the detection of the QRS complexes for ECG segmentation, using a wavelet analysis method, and a hidden Markov model to represent one beat of the signal for P-wave isolation. Then, a set of parameters to detect patients prone to AF was calculated from the P-wave. The detection efficiency was validated on an ECG database of 145 patients, including a control group of 63 people and a study group of 82 patients with documented AF. A discriminant analysis was applied, and the results obtained showed a specificity and a sensitivity between 65% and 70%.

[The best of 2001. Heart stimulation]

Despite the profusion of articles reported in 2001 related to cardiac stimulation, only 5 will be analysed in this review. The choice which has guided this arbitrary selection is the significance of the results for all cardiologists and not exclusively for a group of specialists. Cardiac stimulation continues advancing little by little in the treatment of severe cardiac insufficiency in patients with a complete left branch block. This year the MIRACLE study takes the limelight. Its very clear protocol (stimulation in one group compared to no stimulation in the other) reaches a conclusion which can be considered as indisputable given the large number of patients included: biventricular stimulation significantly improves the functional state of patients at 6 months. In the framework of incapacitating reflex syncope a third randomised study on highly selected patients confirms the indication for this special therapy, which is cardiac stimulation in this situation, even when it is compared with pharmacological "therapy" (betablockade). Syncope, supplying the greatest indication for stimulation, has indisputably made a "breakthrough" in 2001 with the publication of the first recommendations on the subject by a working group of the European Society of Cardiology and thanks to the publication of 2 studies which used implantable Holters to try to clarify their mechanism and to improve the management of patients.

Long-term left ventricular pacing: assessment and comparison with biventricular pacing in patients with severe congestive heart failure

OBJECTIVE

The purpose of this study is to report prospectively the results of six-month follow-up of permanent left ventricular (LV) based pacing in patients with severe congestive heart failure (CHF) and left bundle branch block (LBBB).

BACKGROUND

Left ventricular pacing alone has been demonstrated to result in identical improvement compared to biventricular pacing (BiV) during acute hemodynamic evaluation in patients with advanced CHF and LBBB. However, to our knowledge, the clinical outcome during permanent LV pacing alone versus BiV pacing mode has not been evaluated.

METHODS

Pacing configuration (LV or BiV) was selected according to the physician's preference. Patient evaluation was performed at baseline and at six months.

RESULTS

Thirty-three patients with advanced CHF and LBBB were included. Baseline characteristics of LV (18 patients) and BiV (15 patients) pacing groups were similar. During the six-month follow-up period, seven patients died three BiV and four LV). In the surviving patients at 6 months, 8 of 14 patients in the LV group and 9 of 12 in the BiV group were in New York Heart Association class I or II (p = 0.39). No significant difference was observed between the two groups in terms of objective parameters except for LV end-diastolic diameter decrease (-4.4 mm in BiV group vs. -0.7 mm in LV group; p = 0.04).

CONCLUSION

At six-month follow-up, a trend toward improvement was observed in objective parameters in patients with severe CHF and LBBB following LV-based pacing. The two pacing modes (LV and BiV) were associated with almost equivalent improvement of subjective and objective parameters.

Evaluation of left ventricular function and mitral regurgitation during left ventricular-based pacing in patients with heart failure

BACKGROUND

Beneficial effects of left ventricular (LV)-based pacing on acute hemodynamic parameters were reported in several series, but only a few studies examined the long-term effects of this new pacing procedure.

AIMS

To assess long-term effects of permanent LV-based pacing on LV function and mitral regurgitation (MR) in patients with refractory congestive heart failure (CHF).

METHODS

A prospective evaluation of LV function and MR was performed in 23 patients with severe but stable CHF and left bundle branch block (mean QRS: 186+/-31 ms) by radionuclide and echocardiographic techniques at baseline and 6 months after implantation of a permanent LV-based (LV alone: 13 patients; biventricular: 10 patients) pacemaker programmed either in a DDD mode (sinus rhythm; n=14) or in a VVIR mode (atrial fibrillation; n=9).

RESULTS

Compared to baseline, the 6 months follow-up visit demonstrated a significant increase in radionuclide derived LV ejection fraction from 23.3+/-7 to 26.2+/-7% (P<0.01) and in echocardiographic LV fractional shortening from 13+/-4 to 16+/-6% (P<0.05), without any change in cardiac index, a significant decrease in LV end-diastolic diameter (from 73.2+/-6 to 71.2+/-7 mm; P<0.05), end-systolic diameter (from 63.6+/-6 to 60.2+/-8 mm; P<0.05) and color Doppler MR jet area (from 11.5+/-6 to 6.6+/-4 cm(1); P<0.001). A comparison of patients with LV pacing alone and patients with biventricular pacing showed similar beneficial effects of pacing on MR severity in the two subgroups and a non-significant trend for a better improvement of LV function during biventricular pacing.

CONCLUSION

Thus, in patients with severe CHF and left bundle branch block, permanent LV-based pacing may significantly improve LV systolic function and decrease MR.

[Modeling of coronary arteries and cardiovascular risk factors]

The aim of this study was to assess the impact of cardiovascular risk factors on the modelling of atherosclerotic coronary arteries. One hundred consecutive patients who underwent coronary angioplasty were studied by endocoronary ultrasonography at the site of dilatation. At the site of the treated stenosis of the dilated arteries there was either compensatory widening or positive modelling (PM), or focal contraction or negative modelling (NM) if the total surface area (TSA) of the artery at the site of dilatation was greater or smaller than the total surface area of the proximal or distal reference segments. PM was observed in 53 cases (53%) and NM in 47 cases (47%). Lesions with NM had smaller TSA (13.7 +/- 5.8 versus 20.8 +/- 6.4 mm2, p < 0.0001) and a smaller atheromatous plaque (11.8 +/- 5.6 versus 19.1 +/- 6.5 mm2, p < 0.0001) than lesions with PM. Cardiovascular risk factors such as hypercholesterolaemia, smoking and hypertension were not predictive of either form of arterial modelling and there was no relationship between the cardiovascular risk factors and the qualitative appearances of the plaque studied.

Adverse events with transvenous left ventricular pacing in patients with severe heart failure: early experience from a single centre

AIMS

Assessment of complications following implantation of transvenous ventricular electrodes to pace the left ventricle.

METHODS AND RESULTS

Twenty-eight patients with severe cardiac failure and left bundle branch block were prospectively followed for adverse effects of implantation of a left ventricular transvenous pacing system. Immediate follow-up was associated with loss of left ventricular pacing in nine patients (32%). This was due to lead dislodgement in four cases (corrected by re-operation in three of these cases), and due to increased threshold in five cases (corrected by programming a higher pacing amplitude in all five cases, but with intermittent diaphragmatic contraction in one case). After 1 month, one patient died, one patient with severe coronary heart disease suffered a myocardial infarction, and left ventricular pacing was lost in two patients. Pericardial effusion, new significant ventricular arrhythmias or other adverse effects were not observed. After a mean follow-up of 16 +/- 9.2 months, pacing leads remained stable and no late complications related to the transvenous left ventricular epicardial pacing were observed.

CONCLUSION

Placement of a permanent lead in a tributary of the coronary sinus is feasible without serious adverse effects during the first month. The only frequent adverse event was lead dislodgement; a finding which emphasizes the need for development of specially designed leads for this application.

[Coronary prosthesis implantation. Immediate and mid-term results]

The aim of this study was to evaluate the clinical events occurring after coronary stenting in a series of 318 consecutive patients treated in 1997. Hospital follow-up was by gathering all the data in the hospital record and medium-term follow-up was performed by questionnaire filled with the help of the patient, the attending physician and the referring cardiologist. The primary clinical success rate was 95.6% and the clinical follow-up rate was 98.7%. The follow-up period was at least 16 months (mean 22 +/- 6 months). The restenosis rate was 15% in the remaining population (318-7 deaths and 4 lost to follow-up) and 47% in the population undergoing control coronary angiography. No major clinical cardiac events (death, myocardial infarction or revascularisation) were observed in 80.5% at 1 year and 79% at 22 months. Twenty per cent of the remaining population had no non-invasive paraclinical investigations for myocardial ischaemia after coronary stenting. These results are comparable to those of the literature, indicating excellent feasibility of this technique and the fact that, programmed or not, coronary stenting is a safe procedure confirming its value in what has become everyday practice. Nevertheless, this experience did highlight certain lapses in medical follow-up and patient information.

[The best in 2000 on heart stimulation]

In the last twelve months many important articles have been published in the field of cardiac pacing. The authors analyse 5 of them in this review: the Canadian CTOPP, which compared dual and single chamber pacing in patients with a classical indication for pacing, and concluded that the results were identical in the two modes but not without serious criticism about the validity of this conclusion. A second Canadian trial analysed the effects of atrial stimulation in the prevention of atrial fibrillation but without apparent benefit. In 1999, vaso-vagal syncope had already been studied in a randomised trial; a second one was published in 2000 with concordant results in favour of pacing but reserved for a very selected population. Finally, two articles were devoted to "left heart" pacing in cardiac failure. The MUSTIC trial was the first randomised protocol and its results were favourable for this type of pacing. A physiopathological study reported by a Baltimore group, provided fundamental information: the increase of left ventricular contractility (DP/Dt) occurs without any increase in myocardial oxygen consumption.

[Left ventricular stimulation in treatment of heart failure]

SEARCH FOR AN ALTERNATIVE TREATMENT: The concept of stimulating the ventricle to improve heart function in patients with severe heart failure is an old one, but the first published series was reported about 10 years ago and provided encouraging results that lead to numerous other studies. A PROMISING TECHNIQUE: Excepting a few patients with a long PR, stimulation of the right ventricle is ineffective or even deleterious. Stimulation of the lateral region of the left ventricle has produced some undeniably favorable and sometimes even spectacular improvement in hemodynamic performances. Permanent stimulation of both ventricles or the left ventricle produces an overall clinical improvement in patients with severe heart failure (NYHA III or IV) and major left intraventricular conduction disorders (QRS > 140 ms). These results have been recently confirmed in a prospective randomized trial. CAREFUL OPEN QUESTIONS: There is no fully satisfactory explanation for the improvement which, it is important to note, does not occur in all patients. A more homogeneous contraction of the left ventricle certainly plays a fundamental role. Resynchronization of the two ventricles with dual stimulation is more complex and costly and remains to be evaluated. One crucial question is currently being examined: what is the effect of stimulation on the high mortality in these patients?

Congenital arteriovenous fistulas of the bilateral internal mammary vessels

Internal mammary artery-to-venous fistulas represent a rare cause of a continuous precordial murmur that may be confused clinically with a patent ductus arteriosus. The acquired variety may be secondary to inflammatory, neoplasic, or traumatic events. A congenital fistula may occur as an isolated event, as in the present case, and the question of advisability of endovascular treatment for this patient remains unanswered.

Prevalence of factor V Leiden in patients with myocardial infarction and normal coronary angiography

Factor V Leiden is associated with an increased risk of venous thrombosis and myocardial infarction in young women, but not in men in this latter case. The aim of this study was to evaluate the prevalence of this mutation in patients with myocardial infarction but normal coronary angiography. We compared 3 groups of patients: one group consisted of 107 patients with premature myocardial infarction but no significant coronary artery stenosis; another group of 244 patients with myocardial infarction and significant coronary artery stenosis; a third group of 400 healthy controls. Factor V Leiden was found in 13 patients (12.1%) who had a myocardial infarction without significant coronary artery stenosis, 11 patients (4.5%) who had a myocardial infarction with significant coronary artery stenosis (p = 0.01) and in 20 controls (5%) (p = 0.01). Odds ratio associated with factor V Leiden were respectively 2.93 (CI95: 1.18-7.31 ) and 2.63 (CI95: 1.19-5.78) when we compared myocardial infarction patients without significant coronary artery stenosis to controls or to patients with significant coronary artery stenosis. In myocardial infarction patients without significant coronary artery stenosis, prevalence of factor V Leiden is significantly higher than in controls. This new finding supports the hypothesis that thrombosis plays a key role in this selected situation.

Left ventricular-based pacing in patients with chronic heart failure: comparison of acute hemodynamic benefits according to underlying heart disease

BACKGROUND

Acute left ventricular-based pacing has been shown to improve hemodynamics in patients with severe heart failure and left bundle branch block (LBBB). However, it is not known whether the cause of the underlying heart disease influences the potential effect of left ventricular-based pacing.

OBJECTIVES

The aim of this study was to determine whether beneficial hemodynamic effects of acute left ventricular-based pacing in severe chronic heart failure are dependent on underlying heart disease.

METHODS

After coronary angiography, patients with severe heart failure and LBBB were separated into two groups: dilated (25 patients; 20 male) and ischemic cardiomyopathy (21 patients; 20 male). Hemodynamic parameters were evaluated at baseline and during left ventricular-based pacing.

RESULTS

Improvement in hemodynamic parameters were similar in both groups, during acute left ventricular pacing (changes expressed in percentage): pulmonary capillary wedge pressure, -16+/-15% vs. -14+/-10%; V wave amplitude, -25+/-18% vs. -21+/-17%; and biventricular pacing, -15+/-15% vs. -11+/-11% and -23+/-18% vs. -16+/-18%, respectively.

CONCLUSION

Underlying heart disease does not influence the response to acute left ventricular-based pacing in patients with severe heart failure and LBBB. This finding provides support for including all patients with enlarged heart and heart failure in future studies evaluating left ventricular-based pacing.

[Idiopathic orthostatic tachycardia. Etiology, diagnosis and treatment]

For nearly a century, physicians have been aware of a syndrome consisting of a relatively stereotyped presentation, usually in young patients, who complain of fatigue, malaise and effort intolerance, sometimes of trembling and weakness of the lower limbs. This is associated with an excessive tachycardia in the orthostatic position. This syndrome has recently been called idiopathic orthostatic tachycardia. The tilt test has enabled "quantification" of normal responses. Patients complaining of the symptoms described above and which, during the first minutes of orthostatism, increase their heart rates by more than 30 beats per minute or attain a rate of at least 110/min, are considered to be suffering from this syndrome. The physiopathology is not clear but, globally, there seems to be two sub-groups, the first considered to be a partial dysautonomic disorder and the second, the result of hypersensitivity of the beta-receptors. Besides the tilt test, the diagnosis can also be presumed after an excessive tachycardia response to an intravenous infusion of 1 microgram/min of isoprenaline. The treatment of these patients is uncertain as there is no single approach which is always effective. In addition to "simple" but essential advice, a number of drugs may be used although there is no means of predicting the efficacy of the result in a given patient. A major principle should be emphasised: ablation of the sinus node for inappropriate tachycardia may eliminate the only compensatory mechanism of autonomic dystonia and make the patients even more symptomatic than they were.

Intermittent left coronary occlusion caused by native aortic valve thrombosis in a patient with protein S deficiency

A 77-year-old woman presented with chest pain and cardiogenic shock. Transesophageal echocardiography showed a mobile mass occluding intermittently the left coronary ostium. The mass was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study demonstrated a protein S deficiency. This is the first case of aortic thrombosis associated with protein S deficiency, and it is the first time that transesophageal echocardiography provided definite evidence that a mass can cause intermittent left ostium coronary obstruction.

Use of left ventricular pacing in heart failure: evaluation by gated blood pool imaging

BACKGROUND

Left ventricular (LV) pacing has been suggested to complement other forms of therapy in patients with heart failure.

METHODS AND RESULTS

We investigated 17 patients (15 men, 2 women, aged 68 +/- 6 years, 10 ischemic and 7 primary dilated cardiomyopathy) with heart failure (13 were in New York Heart Association class IV and 4 in class III). One month after LV pacer implantation, 12 patients reported clinical improvement (mean class 3.7 before pacing vs 2.6 with LV pacing; P = .001). We report the results of 3 equilibrium-gated blood pool studies performed in each patient, 1 before pacing and 2 after pacer implantation (1 with pacing on, and 1 after turning off the pacer). LV pacing did not modify LV ejection fraction. Phase analysis demonstrated a significant decrease of the interventricular phase shift (delta(pi)) with LV pacing (no pacing, delta(pi) = 8.99 degrees +/- 19.05 degrees; delta7n= -0.97 degrees +/- 27.85 degrees with LV pacing). Clinical improvement was observed in patients with an initial positive delta(pi) that decreased with pacing and/or an initial LV phase standard deviation >50 degrees that decreased with pacing.

CONCLUSION

LV pacing induces interventricular and intraventricular synchronization. A decrease of the interventricular phase shift seems to be the most important predictor of functional recovery for paced patients with heart failure.

Comparison of oral loading dose of propafenone and amiodarone for converting recent-onset atrial fibrillation. PARSIFAL Study Group

In patients with recent-onset atrial fibrillation (AF), restoration of sinus rhythm is considered to be the first-line therapeutic option. Although this conversion might be obtained by direct-current shock or intravenous antiarrhythmic drugs, administration of an oral loading dose of class I or III antiarrhythmic drugs is more simple and convenient. This prospective, randomized, multicenter study compares the time to conversion to sinus rhythm obtained with an oral loading dose of propafenone or amiodarone. Patients with recent-onset AF (<2 weeks), without contraindications for the 2 drugs, were randomly assigned to be treated with propafenone (600 mg for the first 24 hours and if necessary a repeated dose of 300 mg for 24 hours) or amiodarone (30 mg/kg for the first 24 hours and if necessary a repeated dose of 15 mg/kg for 24 hours). Exact conversion time during the first 24 hours was determined by Holter monitoring. In each treatment group 43 patients with the same baseline characteristics were included. The median time for restoration of sinus rhythm was shorter (p = 0.05) in the propafenone (2.4 hours) than in the amiodarone (6.9 hours) group. After 24 hours (56% in the propofenone and 47% in the amiodarone group) and 48 hours, the same proportion of patients in the 2 groups recovered sinus rhythm (no serious adverse events were noticed). Thus, oral loading dose of propafenone or amiodarone was safe with a similar conversion rate of recent-onset AF. Propafenone had a faster action.

Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation

Acute hemodynamic data of left ventricular based pacing were assessed in 2 groups of patients with severe cardiac failure: 11 patients with atrial fibrillation and 17 patients with sinus rhythm. Both biventricular and left ventricular pacing significantly improved acute hemodynamic findings to a similar degree in both groups, suggesting that left ventricular based pacing may be beneficial in patients with severe cardiac failure regardless of whether or not they are in sinus rhythm.

[Orthostatic hypotension due to autonomous nervous system dysfunction. Review of different syndromes and their treatment]

Dysfunction of the autonomous nervous system was poorly known to cardiologists until recently. Advances in the diagnosis of vasovagal syncope have initiated intense cardiological research into this subject. This type of syncope does not cover by far all dysfunctions of this system, all or nearly all of which have vasoplegic or bradycardic components. The aim of this article is to review the disorders of the autonomous nervous system which may interest every day practice of the cardiologist. The diagnostic advances and new treatments will require a further update of this review in the months or years to come.

Internal right atrial cardioversion of chronic atrial fibrillation: effects of low-energy biphasic shocks

This study evaluates the efficacy and safety of internal right atrial cardioversion of atrial fibrillation using a defibrillation right atrial catheter and 2 thoracic patches with low-energy biphasic shocks.

Angiographic anatomy of the coronary sinus and its tributaries

Permanent left ventricular pacing has been shown to improve the hemodynamic and clinical status of patients with severe heart failure. To pace the left ventricle, the electrode is implanted in tributaries of the coronary sinus (CS). However, the anatomy of cardiac veins with this purpose in mind has not been described in detail.

METHODS

One hundred consecutive patients admitted for coronary angiography had a simultaneous coronary venography performed after the injection of 8 to 10 mL of contrast material into the left coronary artery. Cardiac veins were analyzed in antero-posterior, left anterior oblique 60 degrees, and right anterior oblique 30 degrees views by three different observers. The number, dimension, angulation, and position of the coronary sinus and of its tributaries were studied.

RESULTS

Two veins are consistently present: the middle cardiac vein (mean diameter 2.62 +/- 1.26 mm) and the great cardiac vein (mean diameter 3.55 +/- 1.24 mm). The left posterior vein(s) (LPV) (mean diameter 2.25 +/- 1.2 mm) is (are) variable in number (ranging from 0 to 3), size, and angulation. The absence of LPV limits the ability to pace the left ventricle endovenously. The diameter of the vein (< 2 mm) and its angulation may also complicate the insertion of the lead.

CONCLUSION

Angiographic analysis of dimensions, tortuosity, number, and angulation of venous tributaries of the CS seems to allow the insertion of commercially available pacing leads in approximately 85% of cases. An increase in this percentage hinges on the development of new, dedicated leads.

A method for permanent transvenous left ventricular pacing

LV-based pacing has recently been reported to be of benefit in patients with severe cardiac failure and left bundle branch block. LV permanent pacing has been reported using epicardial leads but the surgical mortality is excessive. A transvenous approach is now favored. In this regard, cannulation of the coronary sinus and of one of its tributaries using only the permanent electrode is feasible but technically challenging. We describe a "long guiding sheath" method using catheterization, and a long radiopaque and peelable sheath. Once the coronary sinus is cannulated with the electrophysiological catheter, the long sheath is advanced to the mid-part of the coronary sinus. The permanent pacing electrode is then placed through the sheath and into a tributary of the coronary sinus. This method has been attempted in 10 patients and was successful in 8, with an average lead insertion time of 21 +/- 5.5 minutes and an average fluoroscopic time of 11 +/- 5.5 minutes. In conclusion, although transvenous left ventricular pacing remains a challenge, the "long guiding sheath" approach appears to facilitate this procedure with both a high success rate and an acceptable procedure time.

[Spontaneous ventilation in positive expiratory pressure in cardiogenic pulmonary edema. Prospective study]

New equipment facilitating the use of spontaneous ventilation with positive expiratory pressure (PEP) has become available in France since January 1996. This technique was applied in 38 patients with severe cardiogenic pulmonary oedema and persistent respiratory distress despite high flow classical oxygen therapy and standard treatment. After 1 hour of ventilation with a flow of 220 l/min of 100% oxygen with an average PEP of 7.7 cm H20, a significant improvement of clinical (heart and respiratory rate) and biological parameters (arterial gases) was observed. There were no side effects. Four patients died during the hospital period and only 1 was intubated. Spontaneous ventilation with PEP is a simple technique for coronary care units and, compared with conventional oxygen therapy, it rapidly improves arterial oxygenation, reduces respiratory work and improves conditions of cardiac load. Acute severe cardiogenic pulmonary oedema seems to be an indication of choice, especially in the elderly, where it may help avoid an often controversial intubation.

[Evaluation of carotid intima-media thickness in patients with severe aortic stenosis. Thrombosis group study in eastern Brittany]

Coronary angiography is a recommended investigation in the preoperative assessment of aortic valve replacement for aortic stenosis in the absence of a reliable non-invasive diagnostic method. Ultrasonographic quantification of carotid artery intima-media thickness, being correlated to the severity of coronary atherosclerosis, could therefore be useful in the screening of coronary artery disease in severe aortic stenosis. The authors studied a group of 100 patients (69.5 +/- 8.5 years: 64 men) with severe aortic stenosis. A control group of 45 patients with coronary artery disease without valvular disease (69.5 +/- 6 years: 30 men) was used for reference. Significant coronary artery disease was found in 21 of the 100 study cases. The average intima-media thickness was 0.608 +/- 0.090 mm. There was no significant difference in intima-media thickness between the coronary and non-coronary patients of the study group (0.612 +/- 0.094 mm and 0.607 +/- 0.094 mm respectively). It was, however, significantly greater in the control group patients compared with the 21 coronary patients in the study group (0.699 +/- 0.082 mm and 0.612 +/- 0.094 mm; p = 0.0004). Finally, 71.1% of patients in the control group had atheromatous carotid artery plaques compared with 59% in the study group (p = 0.005). The measurement of carotid intima-media thickness does not allow detection of coronary patients in severe aortic stenosis. The finding of a lower intima-media thickness in this population compared with coronary patients without valvular disease suggests that aortic stenosis may have a protective effect on the wall thickness of carotid arteries.

Evaluation of different ventricular pacing sites in patients with severe heart failure: results of an acute hemodynamic study

BACKGROUND

Multisite ventricular pacing has recently been proposed as an additional treatment for patients with severe congestive heart failure. To further assess the potential value of this technique, we compared the acute hemodynamic changes associated with pacing the right ventricular apex (RVA) or outflow tract (RVOT) alone, the left ventricle (LV) alone, or biventricular (BIV) pacing of the RVA and LV together.

METHODS AND RESULTS

Acute hemodynamic findings were measured in 27 patients with severe heart failure despite optimal therapy and either first-degree AV block and/or an intraventricular conduction defect. In the 23 patients with a high pulmonary capillary wedge pressure (PCWP) (>15 mm Hg), data were collected after transvenous pacing at different ventricular sites in either the VDD mode (AV delay=100 ms) or the VVI mode in patients with atrial fibrillation (n=6). The mean baseline cardiac index was 1.82 L x min(-1) x m(-2). Mean+/-SD baseline systolic blood pressure (SBP) (118.5+/-15.2 mm Hg), PCWP (26.4+/-6.6 mm Hg), and V-wave amplitude (39.1+/-14.6 mm Hg) were similar before and after either RVA or RVOT pacing. In contrast, LV-based pacing (either LV alone or BIV pacing) resulted in higher SBP (P<.03) and lower PCWP (P<.01) and V-wave amplitude (P<.001) than either baseline or RV pacing measurements. With LV pacing alone, SBP, PCWP, and V waves were 126.5+/-15.1, 20.7+/-5.9, and 25.5+/-8.1 mm Hg, respectively. The results with LV pacing alone were similar to those obtained with BIV pacing.

CONCLUSIONS

In patients with severe congestive heart failure, both LV pacing alone and BIV pacing resulted in a similar and significant acute improvement in SBP, PCWP, and V-wave amplitude compared with baseline measurements and RV pacing alone. These results provide a strong basis for initiating long-term studies examining the chronic effects of LV-based pacing in patients with medically refractory congestive heart failure.

[Systemic embolism in a renal transplant patient. Echocardiographic demonstration of bronchial carcinoma with intracardiac invasion]

A 45 year old female renal transplant patient was admitted for subacute ischaemia of a lower limb. Echocardiography was performed and showed the presence of bronchial carcinoma with intracardiac invasion. The tumour was confirmed by thoracic computerised tomography and by bronchoscopy. Histological investigation of bronchial biopsies and of the arterial embolism extracted at surgery showed large cell malignant disease. The tumour partially responded to chemotherapy and the patient survived for 5 months. Extension of a bronchial carcinoma to the left atrium is a classical complication in autopsy reports but rarely a source of systemic embolism. Echocardiographic diagnosis of this condition is very rare. The incidence of malignant diseases is higher in renal transplant patients than in the general population but this has not been verified for bronchial carcinoma. Echocardiography played an essential role in this case, detecting the tumour and its extension, indicating a poor prognosis and guiding treatment.

[Myocardial infarction caused by acute left main coronary artery occlusion. Apropos of 4 cases and review of the literature]

Between 1979 and 1996, 4 acute occlusions of the left main coronary artery (LMC) were treated by primary transluminal coronary angioplasty. They were 4 men with a mean age of 43 +/- 5 years, admitted to hospital less than 8 hours after the clinical onset of symptoms of anterior myocardial infarction in Killip class 4 with complete right bundle branch block on the initial electrocardiogramme. All cases had a previous history of unstable angina over 2 to 15 days. Angioplasty was undertaken immediately in view of the haemodynamic instability. The coronary circulation was of a dominant right coronary type in the 4 cases: significant stenoses were discovered after recanalisation, on the left anterior descending artery (LAD) in 2 cases and the circumflex or marginal arteries in 3 cases. The right coronary artery was atheromatous in all cases but without significant stenosis. Angioplasty was completed by implantation of a stent in 3 cases (LAD : 1 case, LMC : 2 cases). The outcome was rapidly fatal in 3 cases. Only one patient survived 6 months in functional class 3. These results show that myocardial infarction due to occlusion of the left main coronary artery is a very severe condition which justifies rapid recanalisation. Primary angioplasty with stent implantation in an immediate therapeutic option which enables the patient to survive the acute stage, though only in a limited number of cases.

[Internal atrial defibrillation after failure of attempted pharmacological and electrical cardioversion. Mid- and long-term outcome]

Cardioversion of atrial fibrillation by an endocavitary electrical shock was first proposed during the 1980s. The authors studied the efficacy of this technique at short and medium term in a population of 36 patients (28 men and 8 women) in whom atrial fibrillation persisted despite attempts to reduce it by antiarrhythmic drugs and external electrical cardioversion. The immediate success rate was high : 34 out of 36 patients (94%) and, at medium term, the number with sinus rhythm was comparable to that of studies evaluating the medium-term efficacy of external electrical cardioversion; 19 out of 33 patients (57%) were in sinus rhythm at 6 months and 9 out of 27 patients (33%) at 12 months. These results seem to justify attempts at internal atrial defibrillation in patients in whom the other two techniques of cardioversion have failed. Its use as the method of first intention could be proposed if the profile of "resistant" patients to classical techniques was known, which is unfortunately not presently the case.

Safety of high energy internal cardioversion for atrial fibrillation

High energy internal cardioversion has been proposed as an alternative method to cardiovert drug refractory or external cardioversion refractory atrial fibrillation. However, the safety of this technique has not been clearly evaluated. We reviewed findings in 53 patients who underwent 55 sessions of high energy internal cardioversion (2 patients underwent 2 sessions) for termination of longstanding atrial fibrillation. Shocks energy varied from 70-270 J. Three patients had 3 shocks during the same session, 5 had 2, and 47 only 1. Success rate was 89% (success was defined as immediate conversion to normal sinus rhythm). Low cardiac output occurred in two patients, and resulted in the death of one of these individuals, a patient with significant hypertrophic cardiomyopathy and heart failure. The other patient recovered completely. In 11% of the cases, shock induced transient atrioventricular block, necessitating ventricular pacing until sinus rhythm was restored. In three patients, a moderate but asymptomatic and uncomplicated pericardial effusion was diagnosed on echocardiogram. Finally, four patients had side effects related to venous puncture, which resolved spontaneously. These results suggest that high energy internal cardioversion is effective for conversion of atrial fibrillation. However, the technique may not be optimal in patients with advanced hypertrophic cardiomyopathy and in such cases the technique should be used carefully and only in the case of failure of external cardioversion; no more than two shocks should be delivered during the same procedure. Temporary ventricular pacing should be provided in all patients and an echocardiogram should be performed before patients are being discharged.

[Short and medium-term outcome after radiofrequency ablation of the atrioventricular junction]

The aim of this retrospective study was to assess short and long-term mortality and morbidity after radiofrequency ablation of the atrioventricular junction in patients with supraventricular arrhythmias resistant to treatment. This cooperative series included 91 patients (47 men, mean age 68 +/- 9 years). The arrhythmia was paroxysmal in 56% of cases. The mean duration of symptoms was 67 +/- 61 months and 45 patients (49.4%) were in the NYHA Classes III and IV. An escape rhythm was present in 58 patients with a mean frequency of 39 +/- 9/min. Early complications were observed in 5 patients (venous thromboses, pulmonary embolism, mild pericardial effusion and haemothorax). The hospital mortality was 4 patients (4.4%). Death was of cardiac origin in 1 case (cardiac failure). The mean follow-up of patients was 14.5 +/- 8.6 months. Eleven patients died during this period, 8 of cardiac causes: cardiac failure (3 cases), sudden death (3 cases), thrombosis of a valve prosthesis (1 patient) and major electrolyte disturbances causing loss of stimulation in 1 case. Six patients had recurrences. Long-term morbidity was either related to cardiac pacing (3 cases) or cardiac failure (3 cases). Thirteen patients were in NYHA Classes III or IV at the end of follow-up. The authors conclude that radiofrequency ablation at the atrioventricular junction is an effective method of treating resistant supraventricular arrhythmias. Complications are not frequent but mortality appears to be high, probably due to the presence of advanced cardiac disease in the majority of cases. Sudden death seems to be rare and unrelated to pacing defects.

Postinfarction atrioventricular septal rupture

Postinfarction communication between a left ventricular aneurysm and the right atrium is a rare acquired disease. We report a case of a 72-year-old man who recently had dyspnea on minimal exertion and was found to have left ventricle-to-right atrial shunt by two-dimensional transthoracic echocardiography. This diagnosis was confirmed with transesophageal echocardiography, cardiac catheterization, and angiography. The patient underwent successful repair but died of multisystem failure. This case shows the importance of transthoracic echocardiography for the adequate diagnosis and management of such cases.

Assessment of a newly recognized association. Carotid sinus hypersensitivity and denervation of sternocleidomastoid muscles

BACKGROUND

Carotid sinus syndrome has been reported recently to be associated with chronic denervation of the sternocleidomastoid muscles. To further understand the relationship between carotid mechanoreceptors and sternocleidomastoid denervation, the present study investigated the relation between the results of carotid sinus massage and electromyographic activity of the sternocleidomastoid muscles in patients without syncope.

METHODS AND RESULTS

Patients were selected prospectively if they fulfilled strict exclusion criteria, particularly the absence of a history of syncope, pacemaker implantation, or drugs known to modify the behavior of the autonomic nervous system. A right and left carotid massage was performed for 10 seconds in 30 patients (22 men; mean age, 67.3 +/- 6.5 years). The results (monitoring for heart rate and blood pressure) were classified as normal, doubtful, or hypersensitive carotid sinus. Sternocleidomastoid electromyography activity was recorded from the right and left sides, and the results were classified as normal, moderate denervation, and severe denervation. Carotid sinus massage was normal in 13 patients (43%), doubtful in 9 (30%), and abnormal in 8 (27%). Electromyographic activity of the sternocleidomastoids was normal in 13 patients (43%) and revealed moderate denervation in 7 (24%) and severe chronic denervation in 10 (33%). The results of carotid sinus massage and sternocleidomastoid electromyography were highly concordant in each patient (kappa = .592, P < .00001) and in each side (right, kappa = .381, P < .03; left, kappa = .390, P < .01).

CONCLUSIONS

Carotid sinus hypersensitivity and chronic denervation is a common finding in individuals older than 50 years of age. These two entities are significantly related, suggesting a pathophysiological relation of one to the other.