[Left retroatrial intrapericardial septated hematoma. A rare etiology of anemia after cardiac surgery].
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Publications and source records attributed to C Schurtz.
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The authors report their experience of 2D echocardiography in the acute stage of myocardial infarction. One hundred patients, 60 men and 40 women, aged 60 +/- 4.5 years (range 32 to 69 years) were admitted to hospital with an uncomplicated inferior myocardial infarction and underwent 2D echocardiography on admission and coronary angiography 15 days later. Ten patients were excluded because unsatisfactory quality of the echocardiographic images. Forty-seven patients had initial ST depression of at least 1 mm in leads V1 to V4 (Group I) and 43 patients did not show these electrical changes (Group II). There were no significant differences in the clinical findings or in the cardiovascular risk factors between the 2 groups. On the other hand, inaugural necrosis was commoner in Group II (p less than 0.03) and cardiomegaly and CPK elevation greater in Group I (p less than 0.02). 2D echocardiography demonstrated the same degree of posterior wall hypokinesia or akinesia in the 2 groups. Septal hypokinesia was observed twice as commonly in Group I (p less than 0.03) both at echocardiography and ventriculography. Haemodynamic and angiographic data showed that double and triple vessel disease was commoner (p less than 0.05), that left anterior descending disease was more severe (p less than 0.03), left ventricular end diastolic pressure was higher (p less than 0.02) and the ejection fraction lower (p less than 0.02) in Group I, compared with Group II.(ABSTRACT TRUNCATED AT 250 WORDS)
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Fifty-seven patients who had presented pericardial effusions, compressive in ten cases, were subjected to M. mode echocardiography in order to identify specific signs of cardiac tamponade during major effusions. Certain criteria were of no diagnostic value: right and left ventricular diameter, mitral valve opening amplitude, and aortic diameter (p greater than 0.1). Apart from known hemodynamic and clinical signs, one must bear in mind two echographic signs that are specific for tamponade and disappear after drainage: protosystolic notching on the anterior wall of the right ventricle appearing 0.04 s after QRS, and a slope EF less than 50 mm/s.
One case of chylopericardium associated with chylopneumothorax is reported. Published data make it clear that the pathogenesis of effusions of chyle is imperfectly known and still highly hypothetical. With the exception of tamponade, there are few pathognomonic and dramatic signs. TM and cross-sectional echography is of paramount importance, since it provides a qualitative and quantitative diagnosis of effusion, the nature of which is determined by chemical analysis. Effusions of chyle may be idiopathic or may developed after oesophago-cardio-pulmonary surgery, or even after blockade of lymphatic vessels or as a result of increased lymphatic flow rate or pressure. Although the course of the disease is usually favourable, infectious or haemodynamic complications (e.g. tamponade or constriction) may aggravate the prognosis. Treatment is exclusively surgical and consists of partial pericardectomy, which is unquestioned. There is no consensus of opinion about simultaneous ligature of the thoracic duct.
The predictive value of exercise stress testing was assessed by correlating the results with coronary angiography in a group of 100 patients 50 with inferior and 50 with anterior wall infarction. The following observations were made: --The exercise ECG was positive in 57 p. 100 of cases, more commonly in the inferior infarction group (74 p. 100), ST depression representing over 3/4 of the responses to exercise. On the other hand, the test was only positive in 40 p. 100 of anterior wall infarctions, ST depression again being the most commonly recorded response (65 p. 100). --The overall incidence of post-infarction angina was 45 p. 100; it was more common after inferior (70 p. 100) than anterior infarction (22 p. 100). --Multivessel disease was also more severe in the inferior infarction group (86 p. 100) than in anterior infarction (46 p. 100). However, ventricular aneurysms were twice as common in the anterior infarction group. --Exercise testing detected 80 p. 100 of cases with multivessel disease, especially when the LAD artery was involved, in the inferior infarction group. In the anterior infarction group, almost 50 p. 100 of patients with multivessel disease were not diagnosed. Despite an overall sensitivity of 73 p. 100 the predictive value of exercise stress testing was excellent (84 p. 100). In conclusion, in the presence of persisting angina after myocardial infarction coronary angiography should be performed to determine the severity of the multivessel disease. Exercise stress testing is a useful but imperfect method of detecting this high risk group. Its predictive value is however better in inferior (94 p. 100) than in anterior wall infarction (65 p. 100). Persisting angina was found to be a parameter of very high specificity (100 p. 100) for the presence of multivessel disease.
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The role of echocardiography in the diagnosis and quantitative assessment of pericardial effusion was demonstrated in 57 cases, 10 of which were confirmed by surgery. With this highly sensitive method all effusions equal or superior to 50 ml could be detected and their volume measured with accuracy. There were no false positive results. Two specific signs of tamponade came out very clearly: a decrease in EF slope, which was less than 50 mm/sec, and a notch in the anterior wall of the right ventricle which occurred 0.04 +/- 0.01 sec after QRS.
The author reviews the reported clinical, angiographic and pathological features of Takayashu's disease with coronary lesions with respect to one personal case. Coronary extension of this inflammatory panaortitis presents with effort or resting angina or complications which worsen the prognosis (infarction, arrhythmias, cardiac failure). Histologically, the ostial or truncal lesions correspond to hyperplasia of the three arterial layers, infiltrated with inflammatory cells, oedema, disorganisation of connective tissue, fibrinoid necrosis and fibrosis. The main coronary lesions are best visualised by selective coronary angiography which demonstrates the proximal position of the stenotic or aneurysmal lesions, always associated with a good distal coronary tree. The treatment is essentially surgical by aorto coronary bypass either with a saphenous vein graft or the internal mammary artery. The five reported cases, including the present one, have not been followed up for a long enough period to assess the value of this technically difficult surgery. The results seem to be good in 3 out of the 5 cases. However, the follow up is too short to speak of significant experience in this field, the longest postoperative period being only 3 years.
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Two-dimensional echocardiography has been a decisive advance in the investigation of rheumatic valvular disease. In mitral stenosis, short axis views enable a quantitative evaluation of mitral surface area by planimetry. Long axis views contain additional important information on the state of the subvalvular apparatus and on the possible presence of left atrial thrombosis. The quantitative assessment of regurgitant flow in mitral incompetence is difficult and can only be approximative. On the other hand, the mechanism of mitral incompetence may be clearly demonstrated in: - mitral valve prolapse with the characteristic bowing of the posterior leaflet; - rheumatic mitral incompetence with the abnormal valvular thickening showing the post-rheumatic retractile fibrosis; - ruptured chordae with eversion of the tip of one of the values in the left atrium; - infective endocarditis with ruptured chordae and vegetations; - cogenital mitral incompetence where the superiority of 2D echo over M mode is most marked, the apical incidences demonstrating the high VSD, ostium primum defect and cleft mitral valve. The limitations of the method are also discussed.