[Results of surgical treatment of calcified aortic valve stenosis: report of a series of 4,129 interventions]

Aortic stenosis (AS) is the most common lesion currently encountered among valvular heart disease, particularly in elderly people. Severe functional impairment and risk of sudden death explain that surgical treatment is largely accepted. We report a retrospective analysis of institutional experience with aortic valve replacement (AVR) for AS from 1971-1997 in 4,129 patients. Age ranged from 13 to 91 years (mean 68 +/- 10) and degenerative disease was largely predominant (86%). For AVR, mechanical prostheses were used in 2,054 patients (50.2%) and bioprostheses in 2,075 (48.8%) in elderly group. Coronary artery revascularization was associated in 670 patients (16%). Operative mortality was 7% (303 pts) and main cause was left ventricular failure (52%). Late results were studied with a maximum follow-up of 26 years. Total follow-up represents 21,533 pt-years. Late death occurred in 1,108 patients between 1 month and 24 years after operation (mean 6.6 years). Reoperation was necessary in 136 cases. Actuarial survival--including operative mortality--was 77% and 56% at 5 and 10 years. A large functional improvement was observed in the vast majority of patients, 73% being I or II subgroups of the NYHA classification. Incremental risk factors for death (immediate as well as late) were older age, preoperative functional status, emergency, presence of cardiac failure, coronary artery lesions and associated morbidity. The choice of valvular prosthesis remains controversial, but the results show that AVR is the procedure of choice for the vast majority of patients wtih significant aortic valve disease.

Dynamic analysis of the QT interval in long QT1 syndrome patients with a normal phenotype

AIMS

In families with the long QT syndrome penetrance may be low: up to 70% of gene carriers may have a normal QTc interval. These patients require therapy, similar to that in those with longer QTc intervals, but identifying them, using molecular analysis, is difficult to apply on a large scale. A large French family affected by the long QT1 syndrome was followed-up over a 25-year period. In adult males but not in females, the QTc interval normalized after puberty. We aimed to find clinical criteria, based on ambulatory ECG recordings so that we could improve diagnosis in affected members with a normal QTc.

METHODS AND RESULTS

Linkage analysis and direct sequencing were an indicator of the long QT1 gene in our family. Reverse transcription-polymerase chain reaction analysis demonstrated abnormal transcripts in lymphocytes from silent gene carriers. The functional profile of mutated protein isoforms was investigated using the patch-clamp technique. Dynamic analysis of ventricular depolarization was conducted using Holter recordings in patients, and in sex- and age-matched controls. Circadian variations of the QTc interval and the QT/RR relationship were assessed. Sensitivity, specificity, and predictive values were evaluated for proposed clinical criteria. We found that dynamic analysis of the QT interval permitted individual diagnosis in mutation carriers even when the QTc interval was normal (adult males).

CONCLUSION

Dynamic analysis of the QT interval is of diagnostic value in the long QT1 syndrome in patients with a normal phenotype. Clinical implications include improvement in screening and patient management.

CARDIOMEDIA: a communicable multimedia medical record on Intranet and digital optical memory card

As part of French health reform, French physicians were computerised by the end of 1998. A specific Intranet network will be used to communicate medical data between the health professionals. The objectives of the CARDIOMEDIA project were to develop and evaluate the feasibility of a coronary multimedia data record stored on an optical card and communicable on Intranet within the hospital. Patients treated by angioplasty at the University Hospital of Rennes participated in the experiment. In general, patients are treated in the University Hospital and are followed up by another health care provider closer to their home. The patient leaves the University Hospital with his card, which is directly available elsewhere for emergency or for consultation. This approach is assumed to reduce the number of examinations and to offer a better patient follow-up. The CARDIOMEDIA card is a specialised record including various data types: text, images, image sequences of coronarography and ECG signals. For this purpose an optical card with its large memory is very convenient. We used the DICOM format for image exchange and management. It is combined with CARDIOMEDIA specific compressing software. For the multimedia record the HTML format and web Intranet method are chosen. This provides an intuitive interface which can combine various data types and helper applications like a DICOM image viewer.

Clinical and angiographic results of stenting for long coronary arterial atherosclerotic lesions

A prospective registry of 187 patients who underwent percutaneous coronary angioplasty with attempted long NIR stent delivery was performed. A successful stent delivery was achieved in 93% of cases with a low rate of major cardiovascular events, and 6-month follow-up showed low rates of clinical events, new revascularization procedures, and angiographic restenosis.

Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts

Aneurysms of saphenous vein grafts to coronary arteries are unusual complications of coronary artery bypass graft (CABG) surgery. Three patients (men aged 47, 62, and 68 years) are presented with spontaneous chest pains 10, 21, and 17 years after CABG surgery. In one case, the saphenous vein graft had eroded into the right atrium and had established a fistula between the graft and the right atrium. Diagnosis of saphenous vein graft aneurysms was confirmed by echocardiography, computed tomography or magnetic resonance imaging, and by arteriography. Two patients were treated surgically, the third by percutaneous coil embolisation followed by balloon angioplasty of the right coronary artery.

[Salmonella enteritidis pericarditis. Apropos of a case and review of the literature]

The authors report a case of Salmonella enteritidis pericarditis. The diagnosis was based on bacteriological analyses (blood and effusion cultures and pericardial biopsy). The microbiology of bacterial pericarditis is reviewed underlying the exceptionally rare finding of a non typhi Salmonella in this condition.

Cardiomedia: a multimedia portable medical record on optical memory card

The main objective of the CARDIOMEDIA project is to produce and evaluate a coronarian multimedia data record stored on an optical card. The experimentation concerns patients treated by angioplasty at university hospital of Rennes. Often patients treated in the Regional University Hospital are followed up by another Health structure closer to their home. The patient leaves hospital with his card, which is directly available elsewhere for emergency or for consultation. This will optimize the number of examinations and offer a better patient follow-up. The CARDIOMEDIA card is a specialized record which includes various data type: text, image, image sequence of coronarography and ECG signal. For this purpose optical card with its large memory size is very convenient. For medical imaging, we use in this project the DICOM format for image exchange and management, it is combined with a CARDIOMEDIA specific compressing software. For multimedia record, the HTML format and web intranet method are chosen, this allows intuitive interface which can combine various data type and helpers like DICOM image viewer.

[Loss of a stent in the left main coronary artery and secondary migration into the left circumflex artery needing surgical extraction. Apropos of a case]

The authors report a case of accidental loss of a coronary stent in the coronary arteries and its migration into the circumflex artery. This complication occurred during revascularisation of the left anterior descending artery. In view of a dissection at the site of angioplasty and the migration of the stent, emergency surgery was undertaken comprising bypass grafting of the left anterior descending and arteriology of the left circumflex arteries to recover the stent. This is a rare complication, the frequency is probably underestimated. The authors discuss the factors predisposing to failure of implantation and the means of recovering the stents. The consequences of loss of a stent in the coronary or systemic circulations are also commented.

AREVA: multicenter randomized comparison of low-dose versus standard-dose anticoagulation in patients with mechanical prosthetic heart valves

BACKGROUND

Moderate anticoagulation may be proposed to reduce the risk of hemorrhage for certain patients with a mechanical prosthesis, but the consequences for risk of thromboembolism are debated.

METHODS AND RESULTS

The purpose of the AREVA trial was to compare moderate oral anticoagulation (international normalized ratio [INR] of 2.0 to 3.0) with the usual regimen (INR of 3.0 to 4.5) after a single-valve replacement with a mechanical prosthesis, either Omnicarbon or St Jude. Patients included were between 18 and 75 years old, in sinus rhythm, and with a left atrial diameter < or = 50 mm on the time-motion echocardiogram. Patients were randomized for INR after surgery. From 1991 to 1994, 433 patients underwent valve replacement (aortic, 414; mitral, 19) with 353 St Jude and 80 Omnicarbon prostheses; 380 patients were randomized for INR: 188 for INR 2.0 to 3.0 and 192 for INR 3.0 to 4.5. Mean follow-up was 2.2 years (1 to 4 years). Analysis of 18001 INR samples showed that the mean of the median of INR was 2.74 +/- 0.35 in the 2.0 to 3.0 group and 3.21 +/- 0.33 in the 3.0 to 4.5 group (P < .0001). Thromboembolic events, as assessed from clinical data and CT brain scans, occurred in 10 patients in the 2.0 to 3.0 INR group and 9 patients in the 3.0 to 4.5 INR group (P = .78). Hemorrhagic events occurred in 34 patients in the 2.0 to 3.0 INR group and 56 patients in the 3.0 to 4.5 INR group (P < .01), with 13 and 19 major hemorrhagic events, respectively (P = .29).

CONCLUSIONS

In selected patients with mechanical prostheses, moderate anticoagulation prevents thromboembolic events as effectively as conventional anticoagulation and reduces the incidence of hemorrhagic events.

Surgery for aortic stenosis in elderly patients. A study of surgical risk and predictive factors

BACKGROUND

Aortic stenosis is the most common valvular lesion occurring among elderly patients and has become extremely frequent because of changing demographics in industrialized countries. Surgical risk after the age of 70 has increased. The increasing older age of patients having surgery justifies an analysis of mortality predictive factors.

METHODS AND RESULTS

Between 1976 and February 1993, we performed 2871 operations for aortic stenosis. This study concerns 675 patients (278 men and 397 women) who were > or = 75 years old. Mean age was 78.5 +/- 3 years. Associated lesions were found in 226 patients. A bioprosthesis was implanted in 632 patients (93.6%). Concomitant surgical procedures were performed in 133 patients. Surgical mortality was 12.4% (84 deaths). A longitudinal analysis has been carried out over four successive time periods to evaluate population evolution during these 17 years. Statistical analysis was performed on 46 variables. Multivariate analysis found age (P < .0001), left ventricular failure (P < .0001), lack of sinus rhythm (P < .01), and emergency status (P < .02) to be presurgical independent predictive factors of mortality.

CONCLUSIONS

Risk-reducing strategy should both favor relatively early surgery to avoid cardiac failure and emergency situations and pay careful attention to the use of myocardial protection and cardiopulmonary bypass. Indications for surgery should remain broad since analysis failed to determine specific high-risk groups to be eliminated, and surgery remains the only treatment for aortic stenosis.

[A study of predictive factors of the operative risk in the surgery of aortic valve stenosis in aged patients]

Aortic stenosis, the most extensive form of valvular disease in elderly subjects, has become very common because of demographic reasons in industrialised countries. The operative risk in patients over 70 years of age is significantly higher. The progressive rise in age of patients referred for surgery justifies this analysis of predictive factors of operative mortality. Between 1976 and February 1993, out of 2871 aortic valve replacements, 675 (278 men and 397 women) patients were over 75 years of age and were included in this study. The average age was 78.5 +/- 3 years. Associated pathology was present in 226 patients. A bioprosthesis was chosen in 632 cases (93.6%). An associated surgical procedure was required in 133 cases. The operative mortality was 12.4 +/- 1.3% (84 deaths). Longitudinal analysis was performed for 4 successive periods to assess the outcome of the study population over the 17 years. A statistical study was made of 50 variables and multivariate analysis showed age (p < 0.0001), left ventricular failure (p < 0.0001), non sinus rhythm (p < 0.0005) and emergency procedures (p < 0.02) to be independent preoperative predictive factors of mortality. In order to reduce this risk, the authors recommend early surgical referral to avoid emergency procedures and cardiac failure, and increased efforts of myocardial protection during cardiopulmonary bypass. Despite the risk, surgery is the only radical treatment of aortic stenosis, including elderly patients.

[Diagnostic and therapeutic strategy in coronary insufficiency in the elderly. Apropos of 65 cases]

As people live longer, so cardiologists are having to manage coronary artery disease in progressively older patients with more severe coronary lesions. The authors tried to determine the feasibility and results of coronary angiography in a retrospective study of 65 patients (44 men and 21 women) over 75 years of age (range 75 to 84 years) with coronary artery disease (excluding valvular heart disease). The study period was 22 months. The commonest indication was unstable or invalidating angina resistant to medical therapy (42 of the 65 cases). Twenty-two patients underwent coronary angiography in the context of myocardial infarction complicated in 3 cases by septal rupture. With the exception of these 3 patients, two of whom underwent surgery, 39 of the 62 remaining patients were judged to be candidates for myocardial revascularisation (63%); 37 underwent a revascularisation procedure (60%), 20 by percutaneous transluminal coronary angioplasty and 17 by coronary bypass surgery. The primary success rate of angioplasty was 90% (18 out of 20). There were no deaths in this group. Two patients who were referred for surgery died, an operative mortality of 12% (2 out of 17). All patients were followed up: 56 out of the 65 were still alive at the time of enquiry, after an average period of 18 months. All surviving patients who were successfully revascularised (by angioplasty or surgery) were pauci- or asymptomatic. Although there is an increased mortality related to revascularisation of elderly patients, this would seem to be acceptable given the quality of the medium term clinical results.

[Myxoma of the tricuspid valve. Apropos of a case]

The authors report the case of a chance echocardiographic finding of a tricuspid valve myxoma. Transesophageal echocardiography provided valuable complementary information concerning the precise location of the tumour. Tricuspid valve myxoma is a very rare condition: a review of the literature recensed 16 other cases. This case is of particular interest because of the associated pathological signs: erythemato-papular skin lesions which regresses after ablation of the tumour and a multinodular goitre with a cold isthmic nodule which raised the possibility of the diagnosis of Carney's complex.

Retrieval of a lost coronary stent from the descending aorta using a PTCA balloon and biopsy forceps

We report a case of unsuccessful stenting of a right coronary artery after acute dissection during percutaneous transluminal coronary angioplasty (PTCA). The stent was lost in the descending aorta and we used an original technique to remove it from the arterial bed by using both a very low profile balloon and a 6F bioptome.

[20 years of mitral valve replacement. Development of a patient profile and operative mortality]

Between 1971 and 1991, 1,179 mitral valve replacements (MVR) were carried out in 1,134 patients. The sex ratio was stable over this period (0.7 men/women) whereas the average age of the patients increased by 10 years (50 years in 1971, 61 years in 1991). Since 1980, patients over 60 years of age represent about 60% and those over 70 years of age 16 to 22% of the population. The functional status of the patients has tended to be less severe, the NYHA stages III and IV which were initially preponderant, only represent 50 to 60% of patients operated nowadays. This reduction in the severity of symptoms is reflected in the average value of the cardio thoracic index which was 60 in 1971 and 54.8 in 1991. Similarly, the mean pulmonary artery pressures (measured in 823 patients, 69.8%) have decreased from 37.4 mmHg in 1971 to 29.9 mmHg in 1991. Rheumatic fever has tended to be replaced by degenerative etiologies which, since 1985, represent 40 to 50% of cases. Ischemic mitral regurgitation rare before 1980, is more common, presently making up 5 to 15% of MVR cases. In relation with the etiological changes mitral stenosis is giving way to mitral regurgitation as the commonest valve lesion (40 to 50% of cases in 1991). The annual operative mortality is lower (6 to 8%) than in 1982, despite the increasing number of emergency cases (7 to 10% of cases since 1985). The number of MVR with associated tricuspid valve repair has decreased with respect to isolated MVR or associated with aortocoronary bypass grafting. The only constant feature is the death rate due to myocardial dysfunction which remains over 50% whereas mortality related to the prosthetic valves varied over the years.

[Efficacy of intravenous milrinone in the treatment of acute congestive cardiac failure. Results of a French multicenter study]

The hemodynamic effects and safety of milrinone, a phosphodiesterase inhibitor, were studied in 57 patients in the acute phase of cardiac failure. The drug was given intravenously as an initial push dose of 50 micrograms/kg in 10 min followed by a 24 hour infusion at the dose of 0.5 micrograms/kg/min. Maximal response was obtained after 15 min and persisted throughout the infusion. Cardiac index rose by 40%, while pulmonary capillary pressure fell from 25 mmHg to 17 mmHg (-30%) by the fifth minute of treatment. Mean pulmonary artery pressure fell by 20% by the 15th minute. Systemic resistance decreased by 26% and pulmonary vascular resistance by 22%. All these variations were significant. Heart rate and systemic blood pressure remained stable. Study of three sub-groups: digoxin vs non-digoxin, sinus rhythm vs atrial fibrillation, and coronary patients vs non-coronary patients, revealed no significant difference. Safety of the drug was good, no extra-cardiac actions having required interruption of the infusion. Stoppage was made necessary by two instances of ventricular tachycardia. Improved hemodynamic effects and the good safety/acceptability of the drug indicate that milrinone is a treatment of choice in cardiac failure.

[Immediate and long-term results of 790 mitral valve replacements]

A total of 790 patients underwent isolated (N = 520) or mitral valve replacement associated with a tricuspid valve procedure for lesions excluding post-myocardial infarction mitral regurgitation. The mean age was 54 years: the sex ratio was 1.9 +/- 1.1, female/male. Three hundred and four patients (38.5%) were in the NYHA functional class II and 406 patients (61.5%) were in classes III or IV. The operative mortality was 9.7% (77 patients). The factors associated with a high operative risk were, on multifactorial analysis: double valve replacement, age over 70 years, NYHA class IV, aortic clamp time over 68 minutes and the presence of mitral regurgitation. Seven hundred and four of the 713 survivors were contacted (98.7% follow-up). The average follow-up period was 5.05 years (range 11 to 219 months) giving a total of 3,997 patient-years. The 5 and 10 year actuarial survival rates were 74.7% and 64.7% respectively. The presence of a tricuspid lesion requiring surgical correction, a high NYHA classification and the presence of mitral regurgitation were poor prognostic factors of long-term survival. Three hundred and sixteen of the 533 survivors at the time of the inquiry were in NYHA class I (59.3%), 188 in NYHA class II (35.3%) and 29 in NYHA class III or IV (5.4%). Mitral valve replacement should be considered early as the immediate and long-term results are closely related to the preoperative myocardial function.

[Leiomyosarcoma of the pulmonary artery. Apropos of a case]

The authors report a case of sarcoma of the pulmonary artery in a 41 year old woman hospitalised for syncope on effort associated with effort dyspnoea. Chest Xray and echocardiography were "normal", leading to referral for pulmonary scintigraphy and angiography which showed multiple intravascular filling defects in the pulmonary arterial tree. A tumour implanted on a pulmonary valve was discovered at exploratory thoractomy. It was resected and the pulmonary valve replaced with a Carpentier-Edwards bioprosthesis. The histological findings were those of a leiomyosarcoma. The patient was reoperated 19 months later for a local recurrence but the tumour was too extensive for a complete ablation. The patient developed right heart failure and died the day after surgery. Sarcoma of the pulmonary artery is a rare tumour in adults and carries a very poor prognosis. The clinical course is initially insiduous and polymorphic but early diagnosis and complete excision are the only means of improving survival.

[Aortic valve replacement in persons over 75. 128 operated patients]

Aortic valve replacements are performed in ever older subjects. In the surgical cardiovascular clinic of Rennes, 128 patients aged 75 or over (up to 85 years) and presenting with solitary or predominant (126 cases) aortic stenosis underwent aortic valve replacement between 1976 and 1985 inclusive. Pre-operative evaluation consisted, on principle, of non-invasive explorations. Myocardial protection was ensured by hypothermic cardioplegia. We used a mechanical (Björk-Shiley) prosthesis in the 19 patients operated upon before 1980, and a bioprosthesis (Carpentier-Edwards porcine, supra-annular type since 1983), in the 109 patients operated upon since 1980. The operative mortality rate was 8.6% (11 deaths). The survival curve was similar to that of a control population of the same age-group (survivors 75% at 4 years, operative mortality included). The quality of survival was remarkable since 96% of survivors were in NYHA stages I or II, the poor results being due to early or late cerebral vascular accidents. Advances in surgery (notably myocardial protection), anaesthesia and intensive care make it possible reasonably to operate upon very old patients, provided they have remained in good general and cerebral vascular condition. Non-surgical alternatives, such as percutaneous valvuloplasty, now used in elderly patients can only be reliable if results of similar quality and durability can be expected from them.

[Mid-term outcome of acute right ventricular dysfunction in biventricular myocardial infarction. Hemodynamic and cineangiographic studies]

This study was designed to evaluate the mid-term outcome of the right ventricular (RV) dysfunction which characterizes infarction of both ventricles in the acute phase. Thirteen patients hospitalized for inaugural posterior or infero-posterior infarction extending to the right ventricle (haemodynamic and cineangiographic diagnosis) were explored in the acute phase and 4 months later by right heart catheterization and selective cineangiography of the right ventricle in a 30 degrees RAO projection. The results were compared with those obtained in a control group. Haemodynamically, the RV filling pressures (p less than 0.001) and the indices of RV dysfunction--i.e. RV end-diastolic pressure/RV systolic pressure ratio (p less than 0.001) and right atrial pressure/pulmonary wedge pressure ratio (p less than 0.02)--were significantly decreased between the acute and chronic phases, but they remained pathological compared with those measured in the control group. Angiographically, the right ventricular dysfunction in the acute phase was reflected in an increase of the RV end-systolic volume (p less than 0.02) and a decrease of the RV ejection fraction (p less than 0.01), whereas diastolic cavitary dilatation was inconstant, with mean values of RV end-diastolic volume close to those found in the control group. The systolic dysfunction persisted, unchanged, during the chronic phase. Segmental kinetics of the inferior wall was much reduced in the acute phase (p less than 0.001), this hypokinesia partially regressing in the chronic phase; but in fact there were wide individual variations, and some patients even recovered an almost normal contractility. Tricuspid valve regurgitation was frequent (6/13 cases) in the acute phase and regressed in 2 out of 3 cases in the chronic phase; its presence introduced a degree of bias in the measurement of RV end-systolic volume and RV ejection fraction, with a tendency to underestimate the severity of diastolic dysfunction. To summarize, right ventricular dysfunction was constant but often modest in the acute phase and remained relatively stable at mid-term, whereas segmental kinetics of the inferior wall improved, sometimes dramatically.

[Measurement of right ventricular volume by cineangiography. Validation of monoplane analysis compared with biplane]

It is demonstrated that right ventricular volumes can be measured accurately by biplane cineangiography using the Simpson's rule or various area-length methods. In order to validate the single plane approach a biplane (30 degrees RAO-60 degrees LAO) right ventricle (RV) cineangiography was performed in 10 adults investigated for chest pain without coronary artery disease or any other heart disease. RV volumes (EDV: end-diastolic; ESV: end-systolic; SV: stroke volume) and EF (ejection fraction) were measured by biplane and single plane analysis with the same area-length method using the pyramide with triangular base as geometric model (Ferlinz). The results are: RVEDV (ml/m2) biplane (B) 81 +/- 10, monoplane (M) 82 +/- 11; RVESV (ml/m2) B 33 +/- 6, M 35 +/- 8; RVSV (ml/m2) B 48 +/- 8, M 47 +/- 10; RVEF (%) B 59 +/- 6, M 57 +/- 8. Equations of linear regression show the following correlations: RVEDV R = 0.82 p less than 0.01; RVESV R = 0.77 p less than 0.01; RVSV R = 0.92 p less than 0.001; RVEF R = 0.85 p less than 0.01. Authors conclude to a good enough correlation between monoplane and biplane analysis especially for RVSV and RVEF. They underline the great variability of individual values.

[Surgical correction of chronic tricuspid insufficiency following infarction of the right ventricle]

The case of a 69 year old man with isolated tricuspid regurgitation secondary to right ventricular infarction is reported. The poor long-term tolerance of the regurgitation resulting in severe right ventricular failure in the absence of any left ventricular dysfunction led to tricuspid valve replacement with a bioprosthesis 13 years after the causal infarct.

[Prospective study of the diagnostic and prognostic criteria of right ventricular involvement in the acute phase of inferoposterior infarction]

Right ventricular involvement has been shown to be common in the acute phase of infero-posterior myocardial infarction. The aim of this prospective study was to assess the diagnostic and prognostic value of the different criteria obtained by clinical and paraclinical methods of investigation. Forty patients (35 men, 5 women: mean age 57,1 years) admitted consecutively with this type of transmural infarct without any other cause of acute or chronic volumic or barometric overload of the RV were investigated. In addition to clinical data, the following paraclinical investigations were carried out during the first three days of admission: ECG and vectorcardiogramme (VCG); transaminase levels (SGOT and SGPT), creatinine phosphokinase (CPK), alpha HBDH, serum creatinine, blood gases (pO2), M mode and 2 D echo, right heart catheterisation and cardiac output estimations, selective RV and pulmonary cineangiography centered on the LV in the monoplane 30 degrees LAO projection. Two groups of twenty patients were identified, comparable in age and sex, according to the angiographic extension of akinesia of the RV inferior wall: Group A: extensive akinesia (greater than or equal to 30 p. 100), Group B: very localised or no akinesia (less than 30 p. 100). Analysis of the results showed a number of features characterising patients in Group A: the high incidence of initial shock (45 p. 100 (A)/0 p. 100 (B] and signs of RV failure (85 p. 100/0 p. 100), higher SGOT, SEPT (p less than 0,05) and alpha HBDH (p less than 0,02) but not of CPK; much higher serum creatinine (p less than 0,01) and lower p02 (p less than 0,05); the ECG showed a high incidence (85 p. 100) and specificity (95 p. 100) of ST-T elevation in V3R and V4R, and also 2nd or 3rd degree AV block (60 p. 100/5 p. 100): there were no characteristic VCG changes. Catheterisation showed very significant increases (p less than 0,001) of mean RA, and RV end diastolic pressures, of the RA/mean pulmonary capillary pressure ratio and of Yu's index. There was a moderate increase in PCP (p less than 0,01), a drop in right ventricular systolic work index (RSSWI); adiastole was very common (90 p. 100) and very specific (95 p. 100); angiography showed an increase in RV end diastolic and end systolic volumes (p less than 0,05) and a fall in RV ejection fraction (p less than 0,05) but with a lot of individual variations; there were no significant differences between the two groups as regards the volumes, ejection fractions and p. 100 akinesia of the LV.(ABSTRACT TRUNCATED AT 400 WORDS)

[Exercise tests before and after aortocoronary bypass]

A stress test was performed before and after by-pass grafts in 83 patients. Post-operatively, the number of painful stress tests fell from 68 to 28. Whatever the initial clinical picture (stable angina, anterior or inferior infarct), the improvements is significantly better when all of the lesions have been by-passed. Furthermores, there was no significant change in the maximal performance, but the appearance of pain occurred at much higher values, reflecting the improvement in coronary perfusion and the displacement of the point of appearance of ischaemia.

[Recurrent ejection of aortic valve prostheses. Apropos of 22 case reports]

Twenty two cases of recurrent perivalvular leaks in aortic valve prostheses were reviewed in a multicentre cooperative study. From 1963 to 1978, 22 patients, mean age 39 years, underwent aortic valve replacement; 18 patients had aortic regurgitation, 6 due to infective endocarditis, and 4 patients had calcific aortic stenosis. Eight Starr-Edwards, 6 Smeloff-Cutter, 2 Braunwald-Cutter, 3 Björk, 1 Lillehei-Kaster and 2 bioprostheses were inserted. All 22 patients had to be reoperated for perivalvular leaks due to active or previous infective endocarditis in 7 cases. The prostheses implanted (3 reinsertions, 19 valve replacements) were 10 Starr-Edwards, 4 Smeloff-Cutter, 5 Björk, 1 Lillehei-Kaster, 1 Magovern and 1 bioprosthesis. All 22 patients had further perivalvular leaks, 6 caused by infective endocarditis, and 15 patients underwent a third operation. The prostheses implanted this time (2 reinsertions, 13 valve replacements) were 4 Starr-Edwards, 3 Smeloff-Cutter, 7 Björk and 1 bioprosthesis. Four patients had a third perivalvular leak, and 2 patients a fourth perivalvular leak. The first and second episodes of perivalvular leak were detected early in over half the cases. They were associated with cardiac failure, angina and hemolysis in 20 to 45% of cases. The average period between the first and second operations, and the 2nd and 3rd operations were 15 months and 9 months respectively. Overall, 11 patients died (50%), 4 due to cardiac failure and 3 of sudden death; 3 patients have been lost to follow-up (14%), and there are 8 survivors (36%) with a mean follow-up period of 5 years. However, the mortality rate when the cause of perivalvular leak was infective, was 82%, and only 18% when the cause was mechanical. The factors which favour recurrent perivalvular leaks are infection (30% of cases) and technical difficulties related to the poor quality of the aortic ring (calcification, dystrophy or dilatation). The prevention of this complication depends on careful peroperative technique, the use of certain surgical bypass techniques, a constant battle against infection, and regular examination of operated patients.

[Myocardiopathies during pregnancy. Possible role of beta-mimetics]

The authors report two cases of severe non-obstructive cardiomyopathy presenting at the end of pregnancy in young women treated for long periods and at high dosage with beta 2-adrenoceptor stimulants, prescribed for threatened abortion or premature labour. The circumstances of the presentation, the clinical prescribed for threatened abortion or premature labour. The circumstances of the presentation, the clinical picture and the course towards complete recovery suggest that this might be a pathological process different from "cardiomyopathy of pregnancy" and be an "adrenergic myocarditis" induced or made worse by these drugs. The authors deduce some simple preventive measures.

[The cardiomyopathy of idiopathic hemochromatosis]

A retrospective study of the case histories of 216 patients with idiopathic haemochromatosis has highlighted the frequency of cardiac involvement in this condition (53%). Two forms can be distinguished: a latent one (65%), in which the changes are predominantly electrocardiographic, and a clinical form (35%) with the features of congestive cardiomyopathy, notable for the rapidity of onset after right heart failure, the degree of cardiomegaly, the constant finding of abnormalities of ventricular repolarisation, the relative frequency of latent disorders of supra-His atrio-ventricular conduction, and the finding of elongation of the isovolumic contraction time on the phonomechanocardiogram. A haemodynamic profile is the same as for non-obstructive hypotonic cardiomyopathies, and is usually associated with a slow rise in left ventricular pressure. The cardiomyopathy, which is the most frequent cause of death, determines the prognosis in this condition. It may be found in association with diabetes and gonad failure. The finding of cardiomyopathy indicates basic treatment by veresection, which may be the only means of establishing a favourable outcome.

[Sarcoidosis with extensive ulcerating and atrophying cutaneous manifestations (of the Pick-Herxheimer type) and with cardiac and muscular involvement. About one case (author's transl)]

The authors report an unusual case of chronic sarcoidosis with skin ulcerations and atrophic lesions simulating Pick-Herxheimer's disease. Other severe manifestations are found: cardiac involvement with conduction disturbances and myocardial failure, and muscular involvement which responded well to corticosteroid therapy.

[Familial long QT-syncope syndrome. 2 cases of Romano-Ward syndrome]

Two families with the Romano-Ward syndrome were studied; in family A there were 19 members from three generations, 11 of whom had the abnormality of a long QT interval, 2 of whom had fainting attacks, and 2 of whom died suddenly. In family B, comprising 5 members of two generations, 3 had the anomaly, one of these having fainting attacks, and also having an atrio-ventricular block. The bicycle ergometer test has an important part to play in decisions about treatment of the asymptomatic forms of the condition.

[Infarction of the right ventricle. 1. Hemodynamic diagnosis; pathologic correlations]

70 patients with acute myocardial infarction were submitted to a full haemodynamic assessment at the onset of the condition. In 28 of them there was a disproportionate rise in the right ventricular end-diastolic pressure which could not be explained on the basis of a primary rise in left ventricular filling pressures; these were divisable into two subgroups: -- 19 infarcts without septal rupture, almost all with an inferiorly or posteriorly placed lesion (17); in these cases, an analysis of the curves shows, among other features, a syndrome of adiastole whose three forms (minor, moderate or severe) correlate well with the clinical features. Six cases died, and in four of those it was possible to study the correlation with the post-mortem findings: there were major lesions of the free wall of the right ventricle in 3 cases, but constrictive pericardial changes, the main differential diagnosis of right ventricular infarction, in the fourth. -- 9 cases of necrosis of the septum with rupture, of which only 3 had a syndrome of adiastole; three of these necroses were posterior, and post-mortem examination in two of them confirmed that there were indeed major lesions in the posterior wall of the right ventricle. It therefore seems that the diagnosis of infarction of the right ventricle is a haemodynamic one, and rests especially on the discovery of a syndrome of adiastole. Findings such as these are confined almost exclusively to posteriorly placed infarctions.

[Infarction of the right ventricle. 2. Prognostic and therapeutic aspects]

Infarctions of the right ventricle have a reputation for being innocuous which appears to be unjustified; in a group of 21 patients in whom the diagnosis has been based on the haemodynamic principles put forward in the previous paper, we have had 7 deaths. The prognosis appears to be determined by two types of complication: ruptures of the posterior septum (4 cases), which are very distinctive in their clinical and topographical picture; and haemodynamic complications (10 cases of decompensation) which are related fairly rarely with the lesion of the right ventricle (2 cases), but more often with an associated complication, especially hypovolaemia, in which state the involvement of the right ventricle seems to play a particularly major role in increasing the slowing of the circulation. The proposed treatment plan is aimed at the permanent establishment of an effective circulating volume in the uncomplicated cases; in cases with complications, the aims are twofold--filling of the vascular bed and vasodilators, either separately or simultaneously.

[Mitral stenosis and partial abnormal pulmonary venous return. 3 case reports]

The association of mitral stenosis with an abnormal pulmonary venous return in the absence of an atrial septal defect, is a rare occurrence, and three cases are reported here. If this diagnosis is suggested by the chest Xray, it is confirmed by haemodynamic investigation, which defines the abnormal pulmonary drainage, guages the size of the left-right shunt, and demonstrates the degree of mitral steonsis. If the defect is poorly tolerated, surgical treatment is required.

[Disputable thoracic pain with normal coronary arteries. Metabolic study]

The search for electrocardiographic, haemodynamic and above an metabolic criteria suggestive of "myocardial ischaemia" in the course of an atrial pacing test was found to be positive in three patients suffering from atypical thoracic pains, and in whom selective coronary arteriograms might be considered as normal. It appaear thus that the criterion of a normal coronary arteriography and a negative or unsignificant effort test is insufficient to discard the diagnosis of "myocardial ischaemia" when confronted with such pains habitually considered as anorganic. The accurate mechanism of these pains, probably identical to that or those of "angina with normal coronary arteriography" remains undecided.

[Comparative study of metabolic criteria of acute myocardial ischemia in man]

The study of various myocardial metabolic substrates in basal conditions and in the course of an atrial pacing test in two groups, one control, and the other including angina pectoris in patients with sound coronary arteries, provides the confirmation that the only valid metabolic criterion for acute myocardial ischaemia in man is represented by the decreased extraction or production of lactates. The sugnificance and the specidicity of this parameter is discussed.

[Myocardial infarct in 2 stages]

The two-step myocardial infarction is defined by a peculiar course: the initial stage is a temporary rudimentary infarction, the late stage a typical transmural necrosis, separated by a free interval of a variable duration. A coronary arteriography undertaken when the recurrence starts might eventually lead to recommend an emergency operation: two-step myocardial infarction might represent one of the best indications for emergency aorta-to-coronary artyery by-pass operation.