Biomedical subjects
Publications and source records attributed to J P Houppe.
Appetite suppressants, including aminorex and fenfluramine, have been associated with pulmonary hypertension ever since the well-known outbreak of primary pulmonary hypertension in Europe after treatment with aminorex. The usage of a new anorectic agent, dexfenfluramine, has recently increased dramatically in developed countries. We report 2 new cases of lethal pulmonary hypertension associated with the use of dexfenfluramine.
The authors report the case of an acute anterior myocardial infarction due to occlusion of the left main coronary artery without a collateral circulation. The patient survived after intraaortic balloon pumping followed by cardiac transplantation.
The clinical and echocardiographic features of six patients in whom a right atrial thrombus was detected using two-dimensional echocardiography are reported. In four patients with acute cor pulmonale, the thrombus appeared as a coiled mass moving freely within the right atrium and prolapsing through the tricuspid valve. In another patient referred for syncope, a large coiled mass attached to the lateral wall of the right atrium was seen prolapsing regularly through the tricuspid valve, simulating an atrial myxoma. In the remaining patient who presented with chronic cor pulmonale, two-dimensional echocardiography demonstrated a motionless ovoid mass with a broad base of attachment to the interatrial septum.
In series of 1450 consecutive cardiopulmonary bypasses for cardiac surgery in adults, we observed 20 cases of post-operative compressive pericardial effusion. The effusion occurred some time after the thoracic drains were removed and had to be evacuated. Two-dimensional echocardiography proved essential to the diagnosis : it easily detected the lesion even when clinical symptoms were misleading but above all, it demonstrated, in our series, that the classical post-operative "tamponade" is a specific entity consecutive to posterior, circumscribed, small volume effusions which mainly compress the left cardiac cavities.
The most common lesions of the left main coronary artery are atheromatous lesions (1% of all "coronary patients") but traumatic lesions may occur during coronary arteriography or percutaneous coronary angioplasty. To these must be added severe infectious lesions of the aortic annulus in acute endocarditis affecting the valve or a valvular prosthesis. The 10 cases reported here (4 atheromatous, 1 traumatic and 5 infectious lesions) were treated by transpulmonary repair surgery of the left main vessel. The operations performed were endarterectomy alone (2 cases) or associated with venous graft (2 cases), resection and venous graft (1 case) and suprasigmoidal prosthetic reimplantation (5 cases). There were two early post-operative deaths (one due to major hypocoagulation with secondary hypoxia and one from irreversible cardiogenic shock); another patient died of a ruptured intracerebral mycotic aneurysm 2 months after the operation. The 7 remaining patients have been asymptomatic for 1 year, and angiographies performed on 4 occasions since surgery have given "satisfactory results". The transpulmonary route gives direct access to the left main coronary artery and facilitates a reconstructive surgery adapted to the lesions encountered.
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Six cases of early post-operative coronary artery spasm were observed in a series of 460 consecutive patients who underwent myocardial revascularization. This is a rare accident, only quite recently described. The spasm involves the coronary arterial network or the graft and is reflected in an elevated ST segment accompanied by collapse and ventricular dysrhythmia. The condition may be lethal or may result in myocardial infarction. Treatment consists of calcium inhibitors. The cause of the spasm is unknown, but it seems to be encouraged by trauma of the coronary arteries during surgery and by metabolic changes (production of thromboxane A2) induced by the cardio-pulmonary bypass. This particular spasm must be watched by heart surgeons and their team in order to avoid some deaths and peroperative necroses, as it appears that we are only confronted with its more severe forms.
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The authors report the natural history of 36 patients with end-stage valvular disease defined by the presence of a functional stage IV and/or a 0.60 and/or dilatation of the LA 90 mm and/or dilatation of the LV 70 mm and/or increase in the systolic PAP 80 mmHg and/or a decrease in the EF of 0.45. 11 patients are alive with a mean survival of 36.8 months (30.5%) and 25 have died after a mean interval of 7.8 months. The prognosis is very poor for aortic valvular disease (14 deaths out of 16 cases), but there were only 3 deaths out of 10 patients with isolated mitral valve disease.
Technical advances and progress in resuscitation over the last ten years have led to an appreciable improvement in the surgical results of valve replacements. However, it appears that the decision to operate is sometimes difficult in cases of advanced valvular disease. A study of the literature and our own experience lead us believe that despite a significant peri-operative mortality, surgical treatment remains the best form of treatment for these types of valvular disease, whether aortic, mitral or multivalvular. Surgery ensures a longer survival of better quality than does medical treatment. A better understanding of the natural history of valvular disease should enable us to refer those patients to surgeons who will benefit most from a valve replacement.
Despite the advances made in cardiac surgery, there are still some cases of valvular disease which remain inoperable, i.e. patients who present an operative risk which is too high in relation to the natural history of the disease. A study of the literature does not enable us to define objective clinical or investigational parameters of inoperability, but only factors of poor prognosis. Although there does not appear to be any cardiac contra-indications to valve replacement in cases of advanced valvular disease, the authors stress the importance of the patients general condition which determines the post-operative prognosis and the need for a better definition of the criteria of poor prognosis so that surgery can be performed before it is too late.
The haemodynamic and gamma-angiographic effects of isosorbide dinitrate (ISDN) injection were evaluated in 18 patients with recent myocardial infarction by measuring diastolic (DPAP) and systolic (SPAP) pulmonary artery pressures, diastolic (DAP) and systolic (SAP) systemic arterial pressures, cardiac index (CI) and heart rate (HR). Total ejection fraction (EF) was measured by radionuclide angiography. Within the first hour of treatment, there was a significant fall in DPAP (from 25.11 +/- 6.5 to 18.3 +/- 6 mmHg), SPAP (from 47 +/- 11.5 to 36.6 +/- 10 mmHg) and SAP (from 140 +/- 27.8 to 123 +/- 20 mmHg). Changes in DAP, CI and HR were not significant. The drug produced a significant increase in EF (from 32.6 +/- 15 to 35.3 +/- 15 p. cent). On the basis of these results the patients could be divided into three categories: -- Group I patients (n = 5) with EF greater than 45, in whom the haemodynamic effects (fall in DRAP from 20.8 +/- 4.2 to 16.3 +/- 3 mmHg) and the gamma-angiographic effects (increase in EF from 53.8 +/- 6 to 58.6 +/- 3 p. cent) were favourable. -- Group II patients (n = 5) with EF less than 40, in whom the haemodynamic effects (fall in DRAP from 29 +/- 8.5 to 17.8 +/- 6 mmHg) and the gamma-angiographic effects (increase in EF from 23 +/- 9 to 34 +/- 7 p. cent) were still favourable. -- Group III patients (n = 8) with low EF, in whom there were no significant changes in haemodynamic effects (DPAP from 25.3 +/- 3 to 23.4 +/- 5 mmHg) and gamma-angiographic effects (EF from 26 +/- 6 to 25 +/- 5 p. cent). This group corresponds to cases with very extensive necrosis of unfavourable outcome (4 deaths). One may therefore consider that the lack of effectiveness of ISDN in subjects with left ventricular failure and low EF is of poor prognosis and requires more aggressive therapy.
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A vectorcardiogram (VCG) was recorded in 22 patients in the acute phase of a right ventricular infarct in order to investigate any characteristic signs of this diagnosis. The RV infarct had been proven by at least two investigations: 2D echo, isotopes and right ventricular catheterisation. 17 patients had ST depression in V4R. The QRS complex presented two features: there was a reduced refractory period in every case, associated with septal extension in 3 cases and true posterior infarction in 11 cases, and, in the frontal plane, the QRS which was in clockwise rotation had showed an abnormal left axial lead in 18 cases with a maximal vectorial axis of between - 10 degrees and - 60 degrees. These modifications are similar to those seen in experimental infarcts of the RV. In conclusion, repeated VCGs in the acute phase of inferior infarction should suggest the diagnosis of right ventricular extension if it shows the appearance of more marked left axis deviation than that seen with isolated inferior infarcts. However, this sign is no constant and is not specific.
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