Biomedical subjects
Publications and source records attributed to C Scheublé.
Although many surgical procedures have been proposed to reduce the size of a left atrium, their effectiveness is not well established. We present a case of mitral and tricuspid valve insufficiency with a giant left atrium. Partial heart autotransplantation was used in a mitral and tricuspid valve operation with a successful outcome. This procedure can be an effective method to treat giant left atrium.
The considerable advances achieved in the field of echocardiography have made this investigation an essential diagnostic tool. Under the auspices of the French Society of Cardiology, the Working group on Echocardiography publishes its practical recommendations for optimising the training of echocardiographers (theoretical instruction and practical courses) and for performing echocardiography (understanding the clinical problem, referral to previous examinations, necessary recordings and measurements, and appropriate equipment). In the future, these recommendations should be updated to take into account continuing technical improvements and changes in methods of studying cardiac disease by echocardiography.
A better understanding of the velocity profiles in the cardiac chambers and great vessels should allow more accurate estimation of cardiac output and valve surface area by Doppler echocardiography. The velocity profile in the left ventricular outflow tract was studied by Colour Doppler in 12 patients with pure valvular aortic stenosis with normal left ventricular function and compared with a control population of 12 normal subjects. The selected recordings were digitised and stocked on a laser optic disc. Measurement of the angle of incidence of the line of colour aliasing with respect to the interventricular septum was performed manually on a colour video display unit. A program of digitised image processing allowed the tracing of the axes of reference defining the angle of incidence measured at peak systole. The average angle of incidence was 40.7 +/- 5.6 degrees in the control population and 56.8 +/- 6.8 degrees in aortic stenosis; therefore, in this condition, the angle was significantly flatter (less acute) (p less than 0.001). The correlation between the angle of incidence and the transvalvular pressure gradient was poor (r = 0.24). These results suggest that: real time ambulatory analysis of isovelocity profiles in the left ventricular outflow tract is possible by using the phenomenon of colour aliasing: the presence of an obstacle to left ventricular ejection tends to flatten the velocity profile, justifying the use of the continuity equation in patients with calcific aortic stenosis but questioning its systematic use in control populations of normal subjects used as a reference.
Of all the diagnostic facilities offered by ultrasound in cardiology, clinicians often pause one question: how can valvular regurgitation be quantified by Doppler echocardiography? The large number of articles which have been published in the international literature indicates that there is no simple answer. The aim of this paper is two-fold: firstly, to review the different approaches and underlying "philosophies" and, secondly, to set out a practical strategy for the investigation of the two most important regurgitations, mitral and aortic. The authors conclude this technical presentation with an essential word of caution in the interpretation of the data: concordance of the different indices of severity and clinical coherence of the criteria of evaluation.
Cardiac ultrasonography completed by the Doppler technique has demonstrated his ability to visualize almost all of the anatomical pathology including description and semi-quantification of pathological blood flows within the heart. However, the physical properties of the ultrasound beam frequently limit the imaging process and Doppler flow studies. Absorption of ultrasound by the chest wall is a major determinant of quality and hence interpretation, together with the depth of the examined zone of interest. It's a common finding that echo-Doppler images are better in children than in obese adults. Moreover, strong echo-reflectors, such as calcification or prosthetic heart valves, create large acoustic shadowing effects behind which obtaining an ultrasound signal is difficult if not impossible. For this reason transesophageal echocardiography represents a new essential window into the heart. By positioning a transducer mounted on a fibroscopy sheath into the esophagus in close contact with the left atrium, images of unequaled quality are obtained. An image-resolution of the order of 1-2 mm explains the diagnostic quality in infectious aortic and mitral valve diseases for assessing small vegetations, annular abscesses, and regurgitant lesions by adding color-coded Doppler. The investigation of prosthetic valves dysfunction is completely renewed for detecting disinsertion and thromboses. Heart screening for systemic emboli includes mandatory how the visualization of left (and also right) auricles and the interatrial septum associated with contrast study. Lesions of the descending aorta (aneurysms, thromboses and especially dissections) are perfectly documented in combination with color-Doppler indicating true and false channels as well as re-entry sites. Lastly, other applications are being developed including global and segmental myocardial contractility at rest or even at stress, although this last application is still at the experimental stage. Transesophageal echocardiography therefore appears to constitute a real revolution as an added possibility to the cardiological use of ultrasound: the indication for this "window" being decided for the preferential cases described above only after having performed a standard echo examination. Very often, the indication will be raised by the echocardiographer who, after performing a conventional echo may consider that better or supplementary information could be obtained via the esophageal route. This technique performed by trained operators, is relatively simple, minimally traumatic and can be performed on an outpatient basis provided certain precautions, imposed by the preparation and the consequences of premedication received by the patient, are respected.
A new case of right coronary artery abnormally issued from the pulmonary trunk is reported. The patient was an asymptomatic young man in whom a continuous cardiac murmur was discovered by chance and an angiographic examination disclosed the coronary abnormality. A review of the literature yielded 37 cases of this anomalous origin which was either isolated, as in the case reported here, or associated with another congenital or acquired cardiopathy. The diagnosis may be suspected on the presence of a continuous murmur in an usually asymptomatic subject and is confirmed by angiography. The abnormality is generally well tolerated owing to an inter-coronary collateral circulation resulting in retrograde perfusion of the right coronary artery from the left coronary artery. This good tolerance explains why an isolated abnormality of that type is often discovered belatedly, in contrast with the anomalous origin of the left coronary artery from the pulmonary trunk, which is usually revealed at birth by clinical signs of acute coronary insufficiency. However, the likelihood of either cardiac failure due to the left-to-right shunt in elderly people or, chiefly, acute myocardial ischaemia by coronary steal with a risk of sudden death in young people makes it imperative in such cases to perform reimplantation surgery.
Five men (mean age 39 years) were followed up for 6 to 60 months for tricuspid valve regurgitation caused by a front-to-back injury (in a car in four cases, in an aircraft in one case). The time elapsed between the accident and the signal symptoms varied from 28 days to 20 years. The condition was diagnosed on clinical data (stage 2) and on the results of echocardiography and cardiac catheterization. Four patients were operated upon and provided with a bioprosthetic valve. The post-operative period was marked by resolutive atrioventricular block in one case and inferior myocardial infarction in one case. Four points ought to be highlighted: 1. The long-term development of dilatation of the annulus, cicatricial fibrosis or altered left ventricular contractility; 2. The usefulness of pulsed Doppler echocardiography for the diagnosis and surgical indications (quantification of the regurgitation, right ventricular kinetics); 3. The adaptation of treatment to the lesion: repair whenever possible, or annuloplasty, or bioprosthetic valve replacement (mechanical valves must be excluded); 4. The time for surgery is difficult to determine in view of the asymptomatic period, which may be very long. The decision to operate is based on clinical, echocardiographic, haemodynamic and dromotropic (complete arrhythmia due to atrial fibrillation) data. This decision must be reached before right ventricular myocardial deterioration sets in.
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A series of 45 adults with severe valvular aortic stenosis underwent echocardiographic examination before surgery. The echocardiographic indices of the severity of the stenosis were reviewed: In M mode: aortic valve opening was only clearly defined and quantifiable in 22 out of 45 cases. In these 22 cases, the separation of the valves was variable in 9 cases; the stenosis was underestimated in 2 cases both of which were unsuspected bicuspid valves; the stenosis were overestimated in 1 case leading to an erroneous diagnosis. In 2D: aortic valve opening was easier to detect than in M mode; it was quantifiable in 16 out of 21 patients (80 p. 100). The subcostal view was particularly valuable in patients with chronic pulmonary disease or with barrel-shaped chests. The 2D examination however, suffers from the same limitations as M mode: variability in the values of aortic valve opening in a third of cases and a general tendency to overestimate the severity of the stenosis. In two cases an erroneous diagnosis of severe stenosis was made in cases of simple aortic sclerosis either because of the inability to visualise a mobile 3rd left anterior cusp in the long axis view or because of artefact due to paravalvular calcification. The most reliable index of severity was the thickness of the left ventricular posterior wall: this measurement was never less than 13 mm, with a mean value of 15,8 +/- 1,8 mm in the 43 patients in whom it was measured. The measurement was also of prognostic significance; paradoxical thinning of the posterior wall and septum was a poor prognostic sign which was associated with cardiac failure and passive dilatation of the left ventricle sometimes shortly preceding sudden death. In the absence of cardiac failure, a posterior wall thickness of less than 13 mm excludes surgical aortic stenosis.
A case of a congenital aneurysm of the right anterior sinus of Valsalva (ASV) extending into the septum is reported. The patient, a 20 year old male Central-African, presented with syncopal complete atrioventricular block (AVB) or recent onset. There were no clinical or radiological signs of associated cardiac disease. After implantation of a pacemaker, the diagnosis of an ASV extending into the septum was suggested on routine M mode echocardiography. It was confirmed by two-dimensional echocardiography and aortography. These investigations provided data on its size, its relationship to the cardiac chambers and also showed absence of rupture. The neck of the aneurysm was closed by an endo-aortic approach. There was moderate postoperative aortic regurgitation. This case underlines the value of systematic echocardiography in young patients with AVB of recent onset and obscure origin.
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