Transthyretin amyloid polyneuropathy in France: A cross-sectional study with 413 patients and real-world tafamidis meglumine use (2009-2019)

OBJECTIVE

We aimed to describe characteristics of patients with ATTR variant polyneuropathy (ATTRv-PN) and ATTRv-mixed and assess the real-world use and safety profile of tafamidis meglumine 20mg.

METHODS

Thirty-eight French hospitals were invited. Patient files were reviewed to identify clinical manifestations, diagnostic methods, and treatment compliance.

RESULTS

Four hundred and thirteen patients (296 ATTRv-PN, 117 ATTRv-mixed) were analyzed. Patients were predominantly male (68.0%) with a mean age of 57.2±17.2 years. Interval between first symptom(s) and diagnosis was 3.4±4.3 years. First symptoms included sensory complaints (85.9%), dysautonomia (38.5%), motor deficits (26.4%), carpal tunnel syndrome (31.5%), shortness of breath (13.3%), and unexplained weight loss (16.0%). Mini-invasive accessory salivary gland or punch skin and nerve biopsies were most common, with a performance of 78.8-100%. TTR genetic sequencing, performed in all patients, revealed 31 TTR variants. Tafamidis meglumine was initiated in 156/214 (72.9%) ATTRv-PN patients at an early disease stage. Median treatment duration was 6.00 years in ATTRv-PN and 3.42 years in ATTRv-mixed patients. Tafamidis was well tolerated, with 20 adverse events likely related to study drug among the 336 patients.

CONCLUSION

In France, ATTRv patients are usually identified early thanks to the national network and the help of diagnosis combining genetic testing and mini-invasive biopsies.

Demographic characteristics of the 1902 transthyretin amyloid cardiomyopathy patients treated by tafamidis through the French early access program

Background

Transthyretin amyloidosis (ATTR) is a rare and serious, systemic disease characterized by deposits of amyloid fibrils in various tissues and organs. Tafamidis meglumine is a potent and selective stabilizer of TTR, indicated since 2011 in the treatment of neurological forms of the disease. The French “Agence Nationale de Sécurité du Médicament et des produits de santé” (ANSM) granted a temporary recommendation for use (RTU) on November 28th 2018, based on ATTR-ACT, the pivotal trial results, and designed to enable use of tafamidis meglumine in ATTR cardiomyopathy (ATTR-CM) patients with NYHA I, II and III before marketing authorization. This RTU has been a unique opportunity in France to collect real world data of ATTR-CM patients treated by tafamidis meglumine.

Objective

We aimed to describe the characteristics of ATTR-CM patient treated by tafamidis in the setting of the RTU, over 2 years from November 28th 2018 to November 27th 2020.

Methods

Demographic and clinical data about the diagnosis pathway of patients included in the RTU were prospectively collected using questionnaires, as requested by ANSM to be completed by physicians at the time of tafamidis prescription. A second version of the inclusion form, introduced in May 2020, has allowed collection of additional clinical information.

Results

Overall, 1902 ATTR-CM patients have been included by 189 physicians from 107 centers. Nine centers included each at least 50 patients, accounting for 1092, or 57.4% of all patients. The median age of the patients was 82 years (IQR=9 years), 82% were male, and, 12.4%, 58.8% and 28.7% of patients had a NYHA class of I, II and III, respectively. For almost all patients, the diagnosis of restrictive/infiltrative heart failure was based on heart MRI and/or echocardiography (98.5%; among the 601 patients included from May 2020 28.8% had both exams, 69.7% echo only and 1.6% MRI only), the infiltrative nature of the cardiomyopathy had been confirmed by bone scintigraphy (99.3%), and the absence of light chains had been confirmed by protein electrophoresis or Bence Jones proteinuria (96.6%). Genetic test was performed in 1205 patients (69.4%). Out of the 884 patients who had a genetic test result available at the time of initial prescription, 762 (86.2%) were affected with the wild-type form and 122 (13.8%) with the hereditary form. Among the 601 patients included from May 2020, a hospitalization for cardiovascular condition within the 6 months preceding tafamidis initiation was reported for 22.3% of them, and tafamidis was initiated within 12 months after diagnosis for 92% of them (only 8% initiated the treatment beyond that period).

Conclusion

The RTU program has provided 1902 ATTR-CM patients with early access to tafamidis over 24 months, in France. Overall, as compared to patients included in ATTR-ACT, the pivotal trial, RTU patients were older, the proportion of wild-type was slightly higher, and NYHA distributions were similar.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Early access program sponsored by Pfizer

Smoking and associated unhealthy lifestyle behaviours in patients with chronic cardiac diseases during COVID-19 related lockdown

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Dijon University Hospital France

OnBehalf

CLEO-CD

Background

  Lockdown can affect tobacco smoking (TS) behaviours. 

Purpose

To evaluate the impact of lockdown on (TS) and associated lifestyle behaviours in patients with Chronic coronary syndrome (CCS) and congestive heart failure (CHF)

Methods

CCS and CHF patients were invited to answer to a phone-call questionnaire during the 1st COVID-19 lockdown start 

Results

(Table) 343 questionnaires were fit for analysis, 43 (12.5%) were current smokers (CS). CS were younger (p < 0.001), none stopped and 13 increased their consumption (main reasons were stress and boredom). CS felt more often cramped (p = 0.023). CS who increased their TS consumption showed a trend toward a higher rate of unhealthy lifestyle behaviours

Conclusions

During the lockdown, more than ¼ of CS with CCS or CHF increased their TS consumption and none quitted. Moreover, TS was often associated with other deleterious behaviours increasing their risk for short and long term

Impact of lockdown in patients with congestive heart failure during the Covid-19 pandemic

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Dijon Football Côte d"Or

OnBehalf

CLEO-CD

Background

Congestive heart failure (CHF) can be destabilized by Covid-19 (C19) lockdown.

Purpose

To evaluate the impact of lockdown in CHF patients.

Methods

150 out-patients from the HF Clinic of our hospital were invited to answer to a phone-call interview during the 7th week of first C19 lockdown .

Results

From 124 questionnaires, more than 1/5 felt worse and almost 1/4 declared a psychologic distress. CHF medications were modified in 10%. Decrease in physical activity was observed in 2/5. Almost 1/2 declared increased screen time;  smokers often increased consumption. Adherence to dietary counselling was reduced by 1/6, increase in weight and HF symptoms were common. Some patients benefitted from a teleconsultation.

Conclusions

Our patients exhibited well-being impairment and unhealthy behaviours. Medication adherence was not diminished and the reduction in care access was counterbalanced by a switch toward telehealth.

Main results

	124 patients	75 Male (M)	49 Female (F)	p value between M and F
Age, years	71.0 ± 14.0	68.9 ± 13.7	74.3 ± 14.0	0.03
Urban/Rural	82/42	49/26	33/16	0.84
HFrEF*	87	62	25	<0.001
Dilated cardiomyopathy	50	37	13	0.02
Ischemic	23	18	5	0.06
Other	51	20	31	<0.0001
Current NYHA class I/II/III/IV	39/48/28/9	29/29/14/3	10/19/14/6	0.66
History of NYHA III-IV class	94	62	32	0.03
Electronic device/Telemonitoring	77/28	54/18	23/10	<0.001/0.66
Increase in dyspnea or edema or fatigue	27	13	14	0.07
Decrease in well-being	27	12	15	0.07
Psychological distress (#)	23	15 (20.0)	8	0.64
Weight gain > 2 kg	34	22 (29.3)	12	0.68
Switch for teleconsultation (##)	16	11 (34.4)	5	1
Teleconsultation (total)	23	14	9	1
Decrease in physical activity	52	25 (33.3)	27	0.02
Increase in screen time	57	31 (41.3)	26	0.27
Increase in cigarette consumption (9 smokers)	4	3	1	1
Decrease in dietary adherence (###)	22 (17.7)	15 (20.0)	7 (14.3)	0.47

*HFrEF; # Kessler-6 score ≥ 5; ## from planned physical examination; ### salt, water, alcohol

Risk of atrial fibrillation in hypertrophic cardiomyopathy: a clustering analysis based on the French registry on hypertrophic cardiomyopathy (REMY)

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): CHU Rennes, Inserm, LTSI – UMR 1099, F-35000 Rennes, France Assistance Publique-Hôpitaux de Paris-Centre Université de Paris, University of Paris

onbehalf

REMY register

Paroxysmal or chronic atrial fibrillation (AF) is frequent in hypertrophic cardiomyopathy (HCM),(20%-25% of patients), and is often considered as an important disease turning point. The aim of this study is to determine HCM-phenogroups with different risk of AF-occurrence at 5-year.

We applied the Bayesian method to differentiate phenogroups of patients with different risks of AF across a French hospital registry of adult HCM(REMY). Data were prospectively recorded on 5 years follow-up. 1431 HCM patients were recruited, including 1275 analyzed.

The population included 412 women. AF-occurred in 167 (11.6%) patients. 3 phenogroups were defined according to their common characteristics. Patients at the highest risk were more often female, with more frequent comorbidities, greatest anteroposterior LA diameter, diastolic dysfunction, outflow-tract obstruction or mitral valve abnormality, and presented higher sPAP or right ventricular dysfunction. These also had a higher risk of all-cause hospitalizations and death.

Based on a clustering analysis, 3 phenogroups of HCM according to the risk of AF occurrence can be identified. It can indicate which patients should be more monitored.

3 different AF-risk groups Intermediate risk group n = 524 High-risk group n= 207 Low-risk group n = 544 P Gender = Males (%) 338 (64.5) 103 (49.8) 422 (77.6) &lt;0.001 Age (median [IQR]) 59.00 [47.00, 66.00] 63.00 [54.00, 74.00] 50.00 [38.00, 60.00] &lt;0.001 Stroke (%) 29 (5.5) 44 (21.3) 5 (0.9) &lt;0.001 Right ventricular failure (%) 10 (1.9) 41 (19.8) 0 (0.0) &lt;0.001 None Mitral regurgitation (%) 207 (42.2) 25 (12.6) 416 (81.2) &lt;0.001 Moderate to severe mitral regurgitation (%) 258 (52.6) 143 (72.3) 92 (18) &lt;0.001 Mitral Valve elongation (%) 113 (23.5) 48 (24.9) 62 (12.1) Abnormal insertion of a papillary muscle (%) 13 (2.7) 12 (6.2) 6 (1.2) Mitral valve SAM (%) 214 (40.8) 115 (55.6) 77 (14.2) &lt;0.001 Basal obstruction (%) 196 (37.4) 119 (57.5) 54 (9.9) &lt;0.001 Anteroposterior LA diameter (mm) (median [IQR]) 44.00 [38.00, 49.00] 47.00 [42.00, 51.00] 39.00 [33.00, 43.00] &lt;0.001 Mitral E/e’ Lateral (median [QR]) 10.00 [8.00, 13.53] 15.00 [10.11, 20.00] 7.50 [5.80, 10.00] &lt;0.001 Mitral E/e’ Septal (median [QR]) 15.00 [11.18, 19.55] 18.40 [14.20, 23.50] 10.50 [8.33, 13.88] &lt;0.001 Normal sPAP (%) 354 (82.1) 74 (39.6) 435 (98.0) &lt;0.001 Event AF (%) 80 (15.3) 60 (29.0) 27 (5.0) &lt;0.001 Any cause death (%) 29 (5.5) 36 (17.4) 7 (1.3) &lt;0.001 Any cause hospitalization (%) 174 (33.2) 113 (54.6) 56 (10.3) &lt;0.001 3 different groups on their caracteristics and AF-risk Abstract Figure.

P1277 Cardiac remodeling in secondary tricuspid regurgitation: should we just look at the tricuspid annulus diameter?

Funding Acknowledgements

Financial support: French society of cardiovascular imaging.

Background

The respective strength of the different mechanisms that could lead to significant secondary TR occurrence remains debated.

Purpose

The main objective of our study was to characterize the determinants of tricuspid regurgitation (TR) severity in stable patients with preserved left ventricle ejection fractionand without significant left valvular heart disease. Patients were classified into 5 groups according to echocardiographic TR severity assessment: mild / moderate / severe / massive / torrential. Secondary objectives were to describe the evolution of the dimensions of the right cavities and the right ventricle (RV) function parameters according to the severity of the TR.

Methods

This is a prospective observational and multicentric study. Criteria for inclusion were: age ≥ 18 years; at least moderate TR; euvolemic status. We excluded patients with organic TR. All patients underwent standard trans-thoracic echocardiographyat distance from initial diagnosis and after stable optimized medical treatment. All exams were analysed in a Core Laboratory.

Results

100 patients (12 presented mild TR, 31 moderate, 18 severe, 17 massive and 22 torrential) were enrolled and we used effective regurgitant orifice area (EROA) to quantify the severity of TR. To explain TR severity in multivariate analysis, right atrium (RA) indexed volume and tethering area were statistically significant (p &lt; 0.001). For an increase of 10 mL/m2of RA volume, EROA increases by 4.2 mm2and for an increase of 0.1 cm2of tethering area, EROA increases by 2.2 mm2. The right heart dilation and the degree of restriction of tricuspid apparatus change significantly according to the severity of the TR (p &lt; 0.001). RV function parameters did not differ significantly according to the degree of TR.

Conclusion

Early TA enlargement is present in secondary isolated TR. Then, increase in tethering area and RA indexed volume are associated with increase in TR severity. All right heart cavities dilate progressively without clear impact on RV-function parameters when TR increase.

Factor determining increase in EROA coefficient SD p value RA volume (mL/m2) 0.42 0.09 &lt; 0.001 Tethering area (cm2) 22.1 3.9 &lt; 0.001 Multivariate linear regression model. EROA: Effective Regurgitant Orifice Area; SD: Standard Deviation; RA: Right Atrium.

Abstract P1277 Figure. RV-EDA: probability of TR class severity

P1658Pharmacological treatment of patients with HFrEF: is it really optimized in case of CRT and/or ICD implantation?

Background

Cardiac resynchronization (CRT) as well as implantable cardiac defibrillator (ICD) in primary prevention should be considered in patients with heart failure and reduced ejection fraction (HFrEF) only when pharmacological treatment has been optimized.

Purpose

we sought to analyze pharmacological treatments according to the presence or not of CRT-P, CRT-D or ICD in real life HFrEF patients by using a multicenter survey.

Methods

the survey (NCT01956539) was carried out between 2015 and 2018 in 32 hospitals and included 2735 patients with HF who gave their consent during consultation or hospitalization. In this study, we analyzed only outpatients with chronic HFrEF treated for more than 6 months.

Results

among 1061 patients studied, 138 had CRT-P or CRT-D and 215 had ICD for primary prevention. The main clinical characteristics were: age 65±13 years, ischemic heart disease in, NYHA classes 1, 2, 3 and 4 in 15%, 52%, 23% and 10% cases respectively, systolic blood pressure 115mmHg [IQR 104–129], heart rate 70bpm [IQR 60–80], eGFR 64ml/min/1.73m2 [IQR 46–83]and LVEF was 30% [IQR 24–34]. The table shows the rate of use of evidence-based drugs and the dose for ACEi/ARB and betablockers, according to the presence of ICD or CRT.

HFrEF CRT-P or D ICD (primary prevention) n=1061 n=138 n=215 Loop diuretics 78.2% 79.7% 74.9% ACEi or ARB 65.2% 75.4% 67.3% Sacubitril/valsartan 5.9% 8.5% 9.5% Betablockers 72.3% 83.9% 76.8% Mineralocorticoid antagonists 45.7% 63.6% 60.2% ACEi/ARB mean % maxi dose 77 81 83 Beta-blockers mean % maxi dose 74 63 79

Conclusion

these results suggest that pharmacological treatment remains poorly optimized in a number of patients with HFrEF who received ICD or CRT

132Imaging criteria for the diagnosis of heart failure with midrange and preserved LVEF in the real life

Background

According to last ESC guidelines, the diagnosis of heart failure with midrange and preserved left ventricular ejection fraction (HFmrEF-HF and HFpEF) requires at least one of the following imaging criteria: LV hypertrophy with LVMI >115g/m2 in men and 95g/m2 in women, left atria dilation with LAVI >34ml/m2, TDI e' wave average <9cm/s and E/e' average ≥13.

Purpose

We analyzed the prevalence of these imaging criteria in real life patients who are labeled HFmrEF or HFpEF by using a multicenter survey on HF.

Methods

Our survey (NCT01956539) was carried out in 32 hospitals between 2015 and 2018 and included 2735 HF patients who gave their consent during consultation or hospitalization. The diagnosis of HF was left to the discretion of investigators. Besides clinical and biological data, echocardiographic data (<1 month before or <3 months after inclusion) was collected in an electronic database. No echographic variable except the LVEF was mandatory to be included.

Results

Among the 523 and 765 HF patients who were labeled respectively as HFmrEF-HF and HFpEF, the 4 echographic variables required for the diagnosis of HFmrEF or HFpEF were obtained in 512 patients. The median age was 74y [IQR 62–82], HF was de novo in 28%, AF in 34%, median NTproBNP was 1563 pg/mL [IQR 500–4372]. At least one of the 4 diagnostic criteria was present in all patients but 2, and patients had 2, 3 or 4 criteria in 43%, 37% and 1% of cases. The table shows only little differences between HFmrEF and HFpEF or de novo HF regarding the rate of each diagnostic criteria. There was no difference regarding the date of inclusion, i.e. before or after the last ESC guidelines.

Table 1 All HF patients De novo HF HFpEF HFmrEF mrEF or pEF (n=143) (n=293) (n=219) LVMI >115g/m2 (men) or 95g/m2 (women) 69.6% 64.3% 68.6% 70.2% LAVI >34ml/m2 74.2% 73.3% 80.4% 68.9% e' average <9cm/s 64.1% 55.3% 55.9% 76.1% E/e' average ≥13 35.4% 38.6% 37.3% 32.8%

Conclusion

The diagnosis of HFpEF or mrEF may be difficult and requires comprehensive echocardiography including all diagnostic variables because each single diagnostic criteria are present in only 33 to 80% cases.

Severe cardiomyopathy revealing antineutrophil cytoplasmic antibodies-negative eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of systemic vasculitis in which cardiac involvement is frequent and severe, and accounts for half of EGPA-related deaths. ANCA-positive EGPA differs from ANCA-negative EGPA in that the former is significantly associated with renal involvement, peripheral neuropathy and biopsy proven vasculitis, whereas the latter is associated with cardiac involvement. Herein, we report a case of EGPA with myocarditis in a woman, who was successfully treated with steroids and cyclophosphamide. This report highlights the importance of diagnosing cardiac involvement in EGPA early, especially in ANCA-negative patients.

Measurement of interatrial dyssynchrony using tissue Doppler imaging predicts functional capacity and cardiac involvement in systemic sclerosis

OBJECTIVES

We aimed to assess the prevalence of interatrial electromechanical dyssynchrony in systemic sclerosis (SSc) patients, and to study the correlation between interatrial delay and standard follow-up parameters.

METHODS

Forty consecutive patients with SSc were studied. Classical echocardiographic measurements were obtained, including indices of left ventricular (LV) systolic and diastolic function, right ventricular function, and pulmonary artery pressure (PAP). Left atrial (LA) function was studied using volume measurements. The interatrial mechanical (IAMD) delay was obtained by measuring the time delay between the peak atrial velocities at the lateral tricuspid and mitral annuli using tissue Doppler imaging. A cut-off value of 35 ms was chosen to define the presence of a significant interatrial delay. The IAMD was compared to NYHA class, six-minute walking test (6MWT), NT proBNP levels, and the carbon monoxide diffusion capacity over alveolar volume ratio (DLCO/VA), as well as to classical echocardiographic parameters.

RESULTS

Forty percent of patients were found to have significant interatrial dyssynchrony with an IAMD of 35 ms or more. Patients with interatrial dyssynchrony were more symptomatic, had a shorter 6MWT, higher NT proBNP levels, and a lower DLCO/VA compared with those without dyssynchrony. Regarding conventional echocardiographic parameters, increased IAMD was associated with more pronounced LV diastolic dysfunction, LA enlargement and dysfunction, altered RV function, and higher PAP.

CONCLUSIONS

IAMD correlated with all of the standard follow-up parameters in SSc, and is probably a sensitive marker of LA involvement. This easy to measure parameter should be added to the routine echocardiographic assessment of these patients.

Non-Hodgkin's lymphoma of the heart in patients infected with human immunodeficiency virus

A case of HIV-associated cardiac non-Hodgkin's lymphoma (NHL) is described, and the epidemiologic and clinicopathologic features of 21 cases previously reported in the literature are analyzed. All patients were homosexual males, and the cardiac NHL was the first acquired immune deficiency syndrome-defining condition in the majority. Patients were referred with nonspecific clinical findings including dyspnea and tachycardia, but rapid progression of cardiac dysfunction was frequent after symptoms appeared. Echocardiography constitutes the most useful noninvasive procedure in the diagnosis of cardiac NHL. Most of the patients had disseminated diseased at initial presentation; pathologically, the lymphomas were of B lymphocyte origin and of high-grade subtypes. Prognosis of HIV-associated cardiac NHL is generally poor, although clinical remission has been observed with combination chemotherapy. Cardiac lymphomas in HIV-associated patients are typically high-grade and often disseminate early. Although the prognosis is poor, patients in whom dissemination has not occurred could have longer survival under systemic chemotherapy.

Low-frequency electromyostimulation and chronic heart failure

Low-frequency electromyostimulation (EMS) acts on the skeletal muscle abnormalities that aggravate intolerance to effort in patients with chronic heart failure (CHF). It improves the oxidative capacity of muscles and thus enhances aerobic performance and physical capacity to almost the same degree, as does conventional physical training. No local or hemodynamic intolerance has been reported, even in cases of severe CHF. However, the presence of a pacemaker is one of the relative contra-indications (prior evaluation of tolerance is required), while that of an implanted defibrillator is one of the absolute contra-indications. EMS is an alternative to physical effort training when the latter is impossible due to a high degree of deconditioning or because there is a contra-indication, which may be temporary, due to the risk of acute decompensation and/or rhythm troubles. EMS can also be used in patients waiting for a heart transplant or in CHF patients who are unwilling to engage in physical activities. As EMS is not expensive and easy to set up, its use is likely to develop in the future.

[Acute heart failure and preserved systolic function: can we explain all only by the diastolic dysfunction? A prospective study on 145 patients hospitalized for acute pulmonary edema]

INTRODUCTION

Heart failure with conserved systolic function is frequent and attributed to the diastolic dysfunction. The diagnosis of diastolic heart failure requires the association of clinical signs of heart failure, a conserved left ventricular systolic function and a diastolic dysfunction.

OBJECTIVE

To determine the proportion of cases of isolated diastolic heart failure among patients hospitalized for acute pulmonary edema.

METHODS

The left ventricular ejection fraction (LVEF), the diastolic function and levels of NT-proBNP have been assessed at admission of 145 patients hospitalized for acute pulmonary edema.

RESULTS

49% of patients included were older than 80 years (mean age 78.6 + 0.9 years). Among the 83 patients with conserved LVEF, 25% had an ischemic heart disease, 24% a severe valvular disease, 22% an atrial fibrillation, 5% a severe bradycardia, 2% a severe hypertrophic obstructive cardiomyopathy. Only 15 patients presented an isolated diastolic heart failure. The level of NT-proBNP was correlated to LVEF but was not able to identify those with isolated diastolic heart failure in the group with "conserved systolic function".

CONCLUSION

Among patients hospitalized for acute pulmonary edema, the prevalence of heart failure with conserved systolic function is high, but only 10% of them presented an isolated diastolic heart failure. The NT-proBNP levels do not permit to identify them.

Hypoxaemia associated with an enlarged aortic root: a new syndrome?

OBJECTIVE

To assess the mechanisms through which an enlarged aortic root may facilitate right to left shunting through a patent foramen ovale.

PATIENTS

19 patients with the platypnoea-orthodeoxia syndrome (POS) were compared with 30 control patients without platypnoea.

INTERVENTIONS

Multiplane transoesophageal echocardiography.

MAIN OUTCOME MEASURES

The aortic root diameter, atrial septal dimension behind the aortic root, and amplitude of the phasic oscillation of the septum were measured. Four groups of patients were compared: 12 platypnoeic patients with a dilated aortic root (POS-D), 7 platypnoeic patients with a normal aortic root (POS-N), 15 control patients with a dilated aortic root (CONT-D), and 15 control patients with a normal aortic root (CONT-N).

RESULTS

In POS-D and CONT-D patients, the apparent atrial septal dimension was 16.3 (2.7) mm and 17.4 (5.9) mm respectively, compared with 24.4 (5.2) mm in POS-N patients and 25 (4) mm in CONT-N (p < 0.005). Furthermore, the amplitude of septal oscillation was 14.7 (2.5) mm in the POS-D group versus 5.8 (2.4) mm in CONT-N (p < 0.001) compared with 23.3 (3) mm in seven patients with an atrial septal aneurysm (p < 0.001).

CONCLUSION

Patients with an enlarged aorta have an apparently smaller dimension and increased mobility of the atrial septum. These findings appear to result from compression by the aortic root and decreased septal tautness. Consequently, a "spinnaker effect" with the inferior vena caval flow may take place, opening the foramen ovale and leading to sustained right to left shunting.

["Spontaneous" rupture of the left iliac vein complicating Cockett's syndrome]

The case history reported concerns a female patient aged 42 years for whom the clinical picture was that of a blue phlebitis (phlegmatia caerulea dolens), associated with a state of shock evoking a severe pulmonary embolus. The absence of echocardiographic dilatation of the right cavities, and the appearance of a left iliac fossa mass, steered the diagnosis towards internal haemorrhage. Emergency laparotomy allowed diagnosis and treatment of a so-called spontaneous rupture of the left iliac vein, a rare condition for which 20 cases have been reported in the literature. Re-operation performed 24 hours afterwards for the absence of venous return allowed the discovery of Cockett's syndrome with ascending thrombosis, requiring cross-venous bypass associated with the creation of an arterio-venous fistula in order to maintain permeability. One year afterwards the appearance of signs of cardiac insufficiency led to the closure of this fistula.

[Reversible cardiomyopathy induced by psychotropic drugs: case report and literature overview]

A number of psychotropic drugs, including tricyclic antidepressants, phenothiazine and lithium, have a well demonstrated risk of cardiotoxicity. Each individual therapeutic class has potentially deleterious effects on electrophysiology and myocardial function. The authors report a case showing how serious side effects may result from the association of these different classes in the presence of a coexistent heart disease, even when the underlying disease is mild.

[Cardiogenic shock complicating extensive infarction with ventricular septal defect. Circulatory assistance and heart transplantation]

A 47 year old man had a massive anterior myocardial infarction with cardiogenic shock with a left parasternal murmur. Coronary angiography showed occlusion of the left anterior descending artery for which angioplasty resulted in failure. There was antero-lateral-apical akinesia and a ventricular septal defect (VSD) with a left-right shunt (Qp/Qs = 1.54). Persistence and aggravation of haemodynamic instability led to intra-aortic balloon pumping with inotropic pharmacological support followed by biventricular assistance with a MEDOS device. Under transoesophageal echocardiographic monitoring, the outcome was marked over 7 days by the progressive increase in the shunt volume of the VSD, a decrease of drainage and injection flow, progressive increase in spontaneous contrast echos followed by the presence of fibrin in the cardiac chambers and canulae, the presence of thrombus in the external ventricles, blockage of the right external valve which only opened after increasing the degree of anticoagulation, and, finally, cardiac tamponade which required drainage before the patient's state improved. On the 8th day, the patient being stable with a normal neurological status, the availability of a donor heart led to the decision to transplant, which was carried out without complications. This case poses the problem of cardiac assist devices and their daily monitoring, and then that of cardiac transplantation in this indication.

[Long-term hemodynamic function of the transplanted heart]

The aim of this study was to identify the long-term haemodynamic changes of the transplanted heart. Between 1987 and 1997, 136 patients required cardiac transplantation at Dijon hospital. During follow-up, 76 patients aged 51.2 +/- 9.46 years underwent catheter studies (12 women, 15.8%; and 64 men, 84.2%). Right and left heart catheterisation was performed at 3 months, 1, 2, 3 and 5 years after transplantation. Right heart catheterisation included measurement of mean pulmonary artery and pulmonary capillary pressures and pulmonary arteriolar resistances. During left heart catheterisation, cardiac output, mean aortic pressure, the ejection fraction, the dp/dt max of the left ventricular wall, systemic arterial resistances and left ventricular end diastolic pressures were measured. At each catheter study, the indexed myocardial mass, indexed end systolic and end diastolic left ventricular volumes, the mass/volume ratio, the residual serum cyclosporine concentrations and the serum creatinine were analysed. In addition, an endomyocardial biopsy was also performed. Initially raised, the mean pulmonary artery and pulmonary capillary pressures decrease from the 3rd month to the 2nd year. From the 3rd year onwards, they readjust to the upper limits of normal. The pulmonary artery resistances underwent the same changes. The left heart parameters remained constant over the period of follow-up but with a heart rate, mean aortic pressure and left ventricular end diastolic pressure higher than normal. The indexed myocardial mass was increased at all periods. The indexed left ventricular end systolic and diastolic volumes decreased with a M/V ratio which increased. Cyclosporine concentrations decreased whereas serum creatinine increased. The frequency of severe rejection and of coronary atherosclerosis was low. Significant correlations were observed between different parameters at different periods. In the long-term, the function of the transplanted heart is not normal in the strict sense of the term. The apparent normality is obtained by anti-hypertensive treatment. The transplanted heart adapts to the increase in cyclosporine-induced afterload by permanent myocardial hypertrophy, and increased diastolic pressure probably relates to diastolic dysfunction without noticeable intracardiac fibrosis.

[Randomized comparison of 4F and 6F catheters for diagnostic coronary angiographies via the femoral approach]

The use of 6F catheters has been validated for coronary angiography. The use of small-caliber catheters is a more recent development. The aim of this study was to assess the feasibility, the cost and complications of coronary angiography using the femoral approach with 4F catheters. The authors undertook a randomized prospective study of 4F Care Infiniti catheters (N = 100) and 6F Spertorque Plus catheters (N = 100) in hospitalised patients. Criteria of non-inclusion were valvular pathology, acute myocardial infarction, aorto-coronary bypass or aorto-femoral bypass procedures. No statistical difference was observed between the two groups with respect to feasibility, to duration of the procedure, or of irradiation or to cost. The quality of the angiograms was good except in one patient in the 4F group; 4 patients in the 6F group required a 4F catheter to complete their examination. Left ventricular catheterisation was more difficult with 4F catheters (p = 0.016). Use of 4F catheters was associated with injection of significantly less contrast (p = 0.00007), reduced the duration of compression (p < 10(-6)) and its complications (p = 0.004). The authors conclude that 4F catheters are safe and well tolerated. They are associated with less patient morbidity, without any loss in quality of the angiogrammes. Other studies in valvular heart disease and after coronary bypass surgery should lead to the generalisation of their use in all coronary patients.

Antioxidative properties of pyruvate and protection of the ischemic rat heart during cardioplegia

Formation of oxygen free radicals during heart transplantation seems to be related to the alterations occurring during ischemia and reperfusion and could explain the short preservation time of donor hearts. The aim of our study was (a) to analyze the protective effects of pyruvate during cold cardioplegia and ischemia/reperfusion sequence, and (b) to investigate in vitro the radical scavenging properties of this compound. After 30 min of perfusion, isolated working rat hearts were arrested by cardioplegic solution, stored 4 h in B21 solutions at 4 degrees C, and reperfused with Krebs-Henseleit buffer for 45 min. Pyruvate (2 mM) was added to Krebs-Henseleit, cardioplegic, and storage solutions, and functional parameters were recorded throughout the experiments. In a second part, control hearts and hearts treated with pyruvate were cannulated via the aorta and perfused for 30 min by the Langendorff method, arrested by cardioplegic solution, stored 4 h in B21 solutions at 4 degrees C, and reperfused for 45 min by the Langendorff method. Malonedialdehyde and alpha-tocopherol levels were determined on heart homogenate. In situ detection of apoptotic cells also was performed on tissue samples (left ventricle) at the end of the ischemia/reperfusion sequence. To demonstrate in vitro the antioxidant effects of pyruvate, we monitored (a) its hydroxyl radical scavenging properties by using electron paramagnetic resonance (EPR) spectroscopy, and (b) the decrease of fluorescence of allophycocyanin, in the presence of a Fenton system (H2O2/Cu2+). Ischemia for 4 h, followed by myocardial reperfusion, resulted in substantially reduced mechanical function. Hearts subjected to this ischemia and pretreated with pyruvate showed a significant improvement in the function recovery. After the ischemia/reperfusion protocol, no significant decrease of malonedialdehyde levels was shown on hearts treated with pyruvate. However, alpha-tocopherol levels were higher in the pyruvate group compared with the control group. At the end of the reperfusion period, levels of apoptotic cells were significantly lower in hearts treated with pyruvate compared with control hearts. EPR studies showed that pyruvate was an efficient hydroxyl scavenger, with a median inhibitory concentration (IC50) of 8 mM. The allophycocyanin assay also showed a dose-dependent effect of pyruvate against hydroxyl radicals. In conclusion, these findings showed that pyruvate could prevent reperfusion injuries in the isolated heart, probably by its antioxidative properties. The application of pyruvate may contribute to the preservation of hearts for organ transplantation.

[Ten-year experience with heart transplantation (1987-1997)]

OBJECTIVES

Analyze ten years experience with heart transplantation at the Dijon University Hospital and determine which parameters control mid and long term outcome.

PATIENTS AND METHODS

One hundred thirty six heart transplantations were performed over a 10 year period (1987-1997) in 118 men and 18 women aged 51-87 years. Heart transplantation was indicated on the basis of the following criteria: ejection fraction *20%, pulmonary arteriole resistance < 6 Wood units, peak oxygen uptake < 14 l/kg/min. The Shumway or anatomic technique was used. The triple immunosuppressive protocol combined corticosteroids, azathioprine and cyclosporin. The same team conducted the post-transplantation follow-up with regular programmed consultations in addition to those requested by the general practitioner, the cardiologist or the patient. Follow-up was oriented according to the clinical situation (blood chemistry, cell counts, cyclosporinemia, search for infection, echocardiography, endomyocardial biopsy, coronarography).

RESULTS

Five patients (3.6%) died when still on the waiting list. Absolute emergency transplantation was performed for patients (28.1%) including 8 (5.9%) after circulatory assist. Hospital mortality was 11.7% and late mortality was 16.1%. Actuarial survival was 78% at 1 year, 71% at 5 years and 69% at 10 years. Among the survivors, 94% were taking two, three or even four drugs for hypertension. Cyclosporin levels decreased and creatinine levels increased. Episodes of rejection were minimal: 86.57% of the biopsies were * grade 1 and 4.45% * grade 2. Cytomegalovirus infection was documented and treated in 7.55% of the cases. Incidence of graft coronary artery disease was 3.4% at 1 year, 6.5% at 2 years and 7.9% at 3 years.

CONCLUSION

Our follow-up structure where the same small team conducts regular examinations together with our approach to heart transplantation appears to be the main factor leading to the quality results obtained in this series.

[Long-term follow-up of anatomic heart transplantation. Apropos of 60 patients with a mean follow-up of 36 months]

The aim of this study was to collect different problems seen in long-term evolution of patients who had anatomical cardiac transplantation and to compare with those seen in patients with standard transplantation. During the mean follow-up of 36 months, we analysed different data of 60 patients mean aged 51, who underwent anatomical cardiac transplantation. Six patients (10%) died within the 30 days after surgery. No patient needed the use of permanent pacemaker. Echocardiographic examination found normal atrial shape. One month after surgery, echocardiography described 16 tricuspid regurgitations (22.66%) and 8 mitral regurgitations (13.33%), 1 year later, there was respectively 13.33 and 6.66% tricuspid and mitral regurgitation. We had 8 late deaths: 1 sudden death, 2 chronic rejections, 1 pancreatitis and 4 cancers. The survival analysis pointed out 84% at 1 year, 80 at 2 years, 78 at 3 years and 73 at 5 years. Six months after surgery, 80% of patients were treated for high blood pressure; 85% had serum creatinine level equal or superior to 13 mg/L, with mean serum ciclosporin at 130 ng/mL. At the 3rd month, 6 endomyocardial biopsies were equal or superior to grade 2 rejection (International Society for Heart Transplantation). Between the 3rd and 12th month, 3 endomyocardial biopsies were equal or superior to grade 2 rejection, and the same between the 12th and 24th month. The infections rate was 0.8 episode per patient. Long term follow-up of anatomical cardiac transplantation faces the same problems as in standard cardiac transplantation. It is better to perform anatomical cardiac transplantation because of its early postsurgical advantages. Long term care is the same as in standard cardiac transplantation.

Effects of low-frequency electrical stimulation of quadriceps and calf muscles in patients with chronic heart failure

PURPOSE

The aim of this preliminary study was to evaluate the effects of low-frequency electrical stimulation of quadriceps and calf muscles on global exercise capacities, skeletal muscle metabolism, calf muscle volume, and cardiac output in patients with chronic heart failure.

METHODS

Fourteen patients with chronic heart failure (mean age of 56.4 years +/- 9.1 SD; mean radionuclide left ventricular ejection fraction of 22.3% +/- 8.8 SD) underwent 5 weeks (1 hour per day, 5 days per week) of low-frequency electrical stimulation of quadriceps and calf muscles.

RESULTS

Low-frequency electrical stimulation was well tolerated. Exercise capacity and the calf muscles volumes increased significantly after rehabilitation in comparison with prior rehabilitation (the peak oxygen consumption increased from 17.2 mL/(kgmin) +/- 5.3 SD to 19.6 mL/(kgmin) +/- 5.9 SD; the anaerobic threshold increased from 12.3 mL/(kgmin) +/- 3.2 SD to 15.2 mL/(kgmin) +/- 3.3 SD; the 6-minute walking test increased from 419 m +/- 122 SD to 459 m +/- 114.3 SD; the gastrocnemius volume increased from 259.4 cm3 +/- 58 SD to 273.4 cm3 +/- 74 SD, and the soleus volume increased from 319 cm3 +/- 42.9 SD to 338 cm3 +/- 52.5 SD). The New York Heart Association class was improved after rehabilitation. The P-31 nuclear magnetic resonance spectroscopy of gastrocnemius muscle data were not significantly modified after rehabilitation, thereby inferring that no significant improvement of the muscle metabolism occurred. These data reinforce the hypothesis of an increased muscle mass during stimulation. It is noteworthy that the electrical stimulation did not increase cardiac output at any stage; an enormous asset in favor of this mode of rehabilitation.

CONCLUSION

These results suggest that low-frequency muscular electrical stimulation is well tolerated, induces an increased exercise capacity in patients with chronic heart failure, without an undesirable increase in cardiac output.

Possible association of thrombotic, nonbacterial vegetations of the mitral ring-mitral annular calcium and stroke

Although numerous studies have shown an increased risk of stroke associated with mitral annular calcification, a direct link has rarely been demonstrated. We report the occurrence of long, pedunculated thrombi attached to the calcified mitral annulus in 3 patients who suffered from stroke, with resolution after anticoagulant and antithrombotic therapy.

[Unexplained pulmonary edema: demonstration of obstruction to pulmonary venous return by transesophageal echocardiography. Apropos of 4 cases]

The usual causes of pulmonary edema are left ventricular dysfunction, mitral valve disease or left atrial myxoma. Obstruction to pulmonary venous drainage is a rare and unrecognised diagnosis which should be considered when the usual investigations are unproductive. The authors report four cases in which transesophageal echocardiography showed pulmonary edema to be due to compression of one or more pulmonary veins by a mediastinal mass (2 cases), by the false lumen of dissection of the aorta (1 case) and postoperative stenosis of the pulmonary veins (1 case). These cases underline the diagnostic value of this technique which rapidly provides diagnostic information with privileged visualisation of the pulmonary veins and abnormalities of acceleration of blood velocities in the Doppler mode due to obstruction.

[Outcome of cardiac valve ring abscesses after medical treatment: attempt to identify criteria of favorable prognosis]

OBJECTIVES

Identify factors predicting favorable outcome after medical management of valve ring abscesses in order to propose a surveillance schedule for conservative treatment.

METHODS

A multicentric study conducted from July 1989 to February 1996 included 28 patients (mean age 64 +/- 16 years, range 26-83) hospitalized for active endocarditis and valve ring abscesses diagnosed at transthoracic or transesophageal echography. Conservative medical therapy was given because of a decision of the medico-surgical team (n = 9), high surgical risk (n = 12), or patient refusal of surgery (n = 7). Outcome was favourable in 18 patients (Group I) and unfavorable in 10 (Group II) due to death (n = 9) or subsequent surgery (n = 1). Univariate and multivariate analysis were used to determine differences between the groups in terms of clinical and laboratory data.

RESULTS

Mean follow-up in Group I was 33 +/- 18 months and 15 +/- 10 months in Group II. Univariate analysis showed significant differences between Group I and II respectively for age (59 +/- 18 yr vs 72 +/- 10, p = 0.04), delay to apyrexia after antibiotics (4.3 +/- 2.8 vs 8.3 +/- 2.4 days, p < 0.0008), heart failure (5% vs 70%, p = 0.003), grade III or IV valvular regurgitation (5% vs 60%, p < 0.04), and mean surface area of the abscess (1.5 +/- 1.2 vs 5.4 +/- 6.4 cm2, p < 0.03). Independent factors at multivariate analysis were by decreasing order: lack of heart failure at admission, delay to apyrexia, abscess surface area, and age. Outcome was favorable (mean follow-up 33 +/- 10 months) in all patients with an abscess surface area < 1.5 cm2, no signs of heart failure, no grade III or IV valvular regurgitation, apyrexia after less than 8 days on antibiotics and no staphylococcus positive blood culture.

CONCLUSION

Medical management of valve ring abscesses may be indicated in selected patients in care units with rigorous surveillance facilities. Further studies are needed to precisely identify surveillance and treatment criteria.

[Transesophageal echocardiography in cardiac and paracardiac tumors. A multicenter study]

A multicentre study was undertaken to determine the diagnostic value of transoesophageal echocardiography (TOE) in tumours of the heart and pericardium. Forty-five cases were recensed: 24 myxomas, 1 fibroma, 1 hydatid cyst, 2 lymphomas, 3 sarcomas, 1 pleuropericardial cyst, 1 branchogenic cyst and 12 cardiac metastases. The diagnosis was made in all 45 cases by TOE but only in 35 cases by conventional transthoracic echocardiography which failed to recognise 2 myxomas, 1 hydatid cyst, 1 sarcoma, 2 paracardiac cysts and 4 cardiac metastases. The site of the tumour was identified 45 times by TOE compared with only 12 times by transthoracic echocardiography. However, the anatomical investigation of mediastinal tumours requires complementary computerised tomography. Moreover, TOE, like all other imaging techniques, is unable to predict the benign or malignant nature of the tumour, 1 leiomyosarcoma having been confused with a myxoma.

[Valve ring abscesses: apropos of 59 cases. A multicenter study]

The authors report the results of a multicenter study which recensed 59 cases (46 men, 13 women, average age 59.8 +/- 14 years) of valve ring abscesses defined by echocardiographic criteria alone (20 cases) or by echocardiographic and/or operative criteria (39 cases). The site of abscess was aortic (53 cases), mitral (5 cases) and tricuspid (1 case). The abscess complicated a prosthetic valve in 34 cases, occurred with a non-pathological valve in 11 cases or a pathological valve in 14 cases. Taking the 39 operated patients as a reference, the diagnostic sensitivity of transthoracic echocardiography was 25% and that of transoesophageal echocardiography: 88%. Bacterial vegetations were diagnosed with a sensitivity of 55% for transthoracic and 88% for transoesophageal echocardiography. The mediocre results of transthoracic echocardiography make transoesophageal echocardiography mandatory when there is a clinical suspicion of abscess: transoesophageal echocardiography should be systematic in prosthetic valve endocarditis and widely employed in native aortic valve endocarditis. The clinical outcome of these cases was: 39 cases were operated: global mortality of 23%, and 18 cases were treated medically, surgery having been declined for various reasons: old age (2 patients), operative risk (1 patient), patient refusal (4 patients), general condition considered to be too good to justify surgery (11 cases, including 6 sterilised abscesses diagnosed some time after the acute infectious phase). The outcome of these 18 patients, who form the biggest non-operated series of valve ring abscesses to date, was studied in detail: 4 died (18% mortality), 1 was operated secondarily for progressive valve dehiscence and 13 had a favourable outcome with an average follow-up period of 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

[Purulent pericarditis in dermatopolymyositis]

The authors report the case of a 33-year-old patient with dermatopolymyositis, admitted to hospital for acute cystic pericarditis with fever and deterioration of the general state. The aetiological diagnosis was obtained by analysis of the pericardial fluid after surgical drainage, revealing purulent Staphylococcus aureus pericarditis. This case emphasises that, despite the marked rarity of pericardial effusion in the course of dermatopolymyositis, due to the steroid sensitivity of this disease, the possibility of septic contamination should be considered in the presence of persistent pericarditis in the context of this disease.

[Lipomatous septal hypertrophy. Apropos of 3 cases]

Lipomatous hypertrophy of the inter-atrial septum is characterised by fatty accumulation in the inter-atrial septum. Long unrecognised, it has been discovered anew by virtue of the use of transesophageal echocardiography. The authors report three cases, including one presenting as acute ischemia of the right lower limb. After studying the contribution of imaging techniques to its diagnosis, the authors consider the principal differential diagnoses of this condition.

[Valvuloplasty of a tricuspid bioprosthesis by the Inoue's technique]

The authors report the case of a patient who had undergone tricuspid valve replacement with a bioprosthesis in 1985 after infectious endocarditis complicated by paradoxical embolism. The appearance of signs of right heart failure eight years later led to the diagnosis of stenotic degeneration of the bioprosthesis. Inoue balloon valvuloplasty was performed with no complications leading to significant improvement in the patient's condition.

[Angiosarcoma of the pericardium. Apropos of a case]

Malignant primary cardio-pericardial tumours are rare and difficult to diagnose because of the diversity of their clinical expression. The authors report a case of pericardial angiosarcoma and review the literature, underlining the value of new non-invasive imaging techniques in the diagnosis and surgical approach to obtaining histological confirmation. Magnetic resonance imaging is a valuable tool in this context as it allows scanning of the tumoral extension in all spatial planes and the visualisation of the haemorrhagic signs of malignancy the pericardial effusion related to this pathology.

[Dilated cardiomyopathy disclosing dermatopolymyositis. Management]

Cardiac involvement in dermatopolymyositis is common but rarely symptomatic. Cardiac failure as the presentation is very rare. No correlation exists between the severity of muscular involvement and cardiac involvement. Myocarditis is not uncommon and must be borne in mind if CK MB are above 3% of total CK. It is always associated with electrocardiographic abnormalities. Corticosteroids remain first line treatment. They generally lead to regression of cardiac problems which are usually of secondary importance. If cardiac involvement is severe, the spectacular action of venoglobulins should lead to their use being envisaged from the outset, combined with corticosteroids.

[What are the indications for digitalis glycosides in the current treatment of cardiac insufficiency?]

Digitalis was discovered over two centuries ago and has been in everyday use for 100 years: however nowadays it is not considered to be the almost exclusive treatment of heart failure as it used to be with diuretic therapy. In the last decade, our understanding of the physiopathology of heart failure and the body's mechanisms of adaptation have improved and this has lead to the use of new molecules and a different approach to the problem of left ventricular failure. The classical contra-indications and precautions of use of digitalis have been studied in detail. The use of digitalis is contested especially in patients in sinus rhythm or with ischemic heart disease and it is used less often in adult cardiac emergencies. The competition between digitalis and vasodilator therapy is now very apparent in some situations; however, the choice between these two groups of drugs (as treatment of first intention or in association) has to be carefully considered in each individual case. The future of digitalis therapy lies without doubt in pediatric cardiology where it remains irreplaceable.

[Right-left auricular shunt caused by patent foramen ovale at a multi-purpose intensive care unit. Apropos of 3 cases]

Three cases of symptomatic right-to-left interatrial shunt through a patent foramen ovale were detected in the course of a case of paradoxical embolism related to a massive pulmonary embolism, a case of refractory hypoxemia after cardiopulmonary bypass and a case of refractory hypoxemia in a patient with tricuspid endocarditis. According to anatomic studies, the incidence of patent foramen ovale is 25-30% in healthy people. In that case any pathological event generating an increase in the right atrial pressure higher than the left atrial pressure may induce a right-to-left shunt with systemic arterial desaturation and possible paradoxical embolization. The reported cases emphasize the advantage of ultrasonic examinations (contrast sonocardiography, pulsated or coloured Doppler) to show the right-to-left atrial shunt. The demonstration of this acquired shunt requires appropriate measures in order to reverse the atrial gradient. Sometimes a specific therapy is required such as caval filter insertion in case of pulmonary embolization or surgical closure of foramen ovale in some patients.

[Transesophageal stimulation in the treatment of atrial flutter and tachysystole. Factor influencing immediate results]

The effectiveness and safety of transoesophageal atrial pacing in the treatment of atrial flutter and tachycardia have been well demonstrated. The purpose of this study was to determine the factors that could influence the results of this method at the end of the procedure. Seventy-seven transoesophageal atrial pacings were performed in 62 unselected consecutive patients with either flutter or atrial tachycardia. The following parameters could be evaluated in 55 patients: date of onset of the arrhythmia, echocardiographic diameter of the left atrium, maximum amplitude of oesophageal atrial potentials, voltage and frequency of stimuli in the last stage of pacing. Our results can be summarized as follows: In both flutter and atrial tachycardia taken globally, conversion to sinus rhythm was obtained in 37 p. 100 of the cases, and conversion to atrial fibrillation in 46.7 p. 100 of the cases. The failure rate was 19.4 p. 100; all failures were due to lack of atrial capture during pacing. The main factor or transoesophageal atrial capture is voltage. Patients must be able to tolerate the voltage needed for capture. In the case of flutter, when capture was achieved a normal-sized left atrium and a high maximum amplitude of oesophageal atrial potentials were factors indicating that conversion to sinus rhythm could be expected. This, however, did not apply to atrial tachycardia. -- Whatever the type of tachyarrhythmia, the more recent its onset the easier its reduction.

Acute renal failure during nifedipine therapy in a patient with congestive heart failure

A patient with congestive heart failure and normal renal function developed anuria during treatment with nifedipine. This acute renal failure was reversible after discontinuing the drug. Other possible causes of renal function deterioration were excluded. We suggest that nifedipine may have acutely altered renal hemodynamics.

Congenital diverticulum of the right atrium situated on the floor of the coronary sinus

A diverticulum of the right atrium was found on the floor of the coronary sinus in a neonate. The diverticulum was distinguished from a pericardial cyst by contrast echocardiography, and its relations with coronary sinus and coronary venous return were identified by coronary angiography. Because the diverticulum compressed the left ventricular inferior wall and prevented its growth, it was excised. Thebesian veins were discovered at operation and prevented complete correction of the defect.

[Tricuspid endocarditis with right-left auricular shunt through a patent foramen ovale]

The authors report the case of a tricuspid endocarditis secondary to Streptococcus bovis with important regurgitation and severe hypoxemia secondary to a right-left atrial shunt through a patent foramen ovale, requiring a surgical treatment which included the replacement of the tricuspid valve and closure of the dehiscence in the inter-atrial septum. The presence of a patent foramen ovale in the course of a tricuspid endocarditis has been exceptionally reported. This diagnosis deserves to be evoked in case of an unexplained hypoxic condition or a systemic embolism complicating a tricuspid endocarditis. The report emphasizes the advantage of ultrasonic examinations (contrast sonocardiography, pulsated Doppler) in order to demonstrate this right-left atrial shunt in addition to the data collected about the tricuspid valve.