Biomedical subjects
Publications and source records attributed to M Baudouy.
The case of a young woman with clinical and biological manifestations suggestive of a pheochromocytoma primarily producing dopamine is reported. Whether endogenous production of dopamine was due to a tumor or to a metabolic abnormality remained unclear.
This study reports 15 cases of ischaemic clinical forms of hypertrophic cardiomyopathy (HCM). In this retrospective study over a 3 year period, 15 patients with HCM presented with clinical and electrocardiographic signs simulating unstable angina (N = 5) or myocardial infarction (N = 10). All patients had chest pain lasting at least 20 minutes with pseudo-ischaemic ECG changes. Two patients were given thrombolytic therapy. The clinical and enzymatic outcome and results of complementary investigations (including coronary angiography) confirmed the absence of coronary artery disease. The diagnostic of HCM was made by echocardiography. These cases were all apparently primary forms of HCM without intraventricular pressure gradient under basal conditions. Three of the patients were known cases of HCM but the condition was diagnosed after the ischaemic presentation in the other cases. Eight of them had however been considered to have had coronary insufficiency for an average of 5 years. The clinical presentation of HCM represents a difficult differential diagnostic problem with myocardial infarction. Echocardiography is of little help in distinguishing the 2 diseases as septal hypokinesis is often observed in HCM. The clinical course usually reestablishes the diagnosis within a few hours but the delay is often too long in this situation of therapeutic emergency and the indications of thrombolysis may be wrongly posed. Although there is no available formal means of distinguishing the two conditions, this study underlines that this clinical form of HCM is not rare and that the diagnosis should be keep in mind with the other differential diagnoses of myocardial infarction.
The classification of hypertrophic cardiomyopathies remains a thorny nosological problem. Within this extensive diagnostic group, it is felt that the very special sub-group of "Japanese" apical hypertrophic forms must be subject to the strictest possible criteria in order to avoid improper use. The case reported here of biventricular apical hypertrophic cardiomyopathy in a 60-year-old woman with a family history of HCM, in whom the clinical, ECG and above all angiographic features were typically those of AHCM but where the existence of an intraventricular gradient was found during challenge manoeuvres emphasises this classification problem. Pseudo-AHCM in a context of OCM or pseudo-OCM in a context of AHCM? The discussion is not merely of nosological interest in view of the recently documented clear prognostic differences between these two conditions. Main series from the literature are reviewed.
Cardiogenic shock is a very serious complication of acute myocardial infarction because of its prevalence (10-15% of cases) and the associated mortality of 80 to 90 per cent despite the availability of new inotropic drugs and intra-aortic balloon counterpulsation. The aim of this study was to show that revascularisation by percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction complicated by cardiogenic shock completely changes the prognosis. Between April 1985 and February 1988 emergency PTCA was carried out in 25 patients in cardiogenic shock defined as systolic hypotension (less than 80 mmHg) and clinical signs of peripheral or cerebral hypoperfusion. The patients were 21 men and 4 women with an average age of 62.7 +/- 6.7 years. The average delay before hospital admission was 122 mn (range 30 to 240 mn--40%--). External cardiac massage for ventricular arrhythmias or circulatory arrest was required in 56 per cent of cases and 20 per cent underwent balloon angioplasty during resuscitation. Five patients died in the catheter laboratory and 7 others during the hospital period. Thirteen patients (53%) survived and were discharged home. There have been no late deaths during the 24 month follow-up period; 46 per cent asymptomatic, 38 per cent in Class II and 16 per cent in Class III. Survival was better in the last 15 patients undergoing emergency angioplasty: 66 per cent compared with only 30 per cent in the first 10 patients in whom the decision to perform PTCA was then late, after failure of thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Arteriovenous fistula is one of the main causes of high output cardiac failure. The authors report a case following lumbar disc surgery. There are a number of features which may suggest this complication both during surgery and in the immediate postoperative period which are important because the patient may only become symptomatic a long time after operation with a clinical presentation which leads to a cardiological rather than to a surgical referral.
The beta-adrenoceptors are now well individualized. They are divided into three distinct units: the receptor site, a regulating protein and a catalytic unit. The receptor density of the cell membrane varies according to the degree of stimulation of the receptor by agonists or the degree of blockade by antagonists. The myocardial or lymphocytic beta-adrenoceptor density is measured by "radioreceptor" assay using a radioactive beta-blocker. The myocardial beta-receptor density falls during heart failure, mainly to the detriment of beta 1 receptors. The density of beta 2 receptors remains unchanged. This fall in beta 1 receptors is related to the increase in the circulating catecholamines (down regulation) and is proportional to the severity of the disease. These physiological and physiopathological consequences can be directly applied to the treatment of heart failure by positive inotopic drugs or by beta-blockers.
The authors report the case of a myocardial abscess in an infectious endocarditis with a double localization, mitral and aortic. The way it is revealed, by severe and recurring ventricular arrhythmias, differs from the conduction disorders usually described. The diagnosis is suspected by non-invasive examinations, echocardiography and nuclear magnetic resonance. It is backed up by angiographic exploration. The intervention confirms the data obtained by cardiac imaging, and enables the ablation of the abscess which is cleaned out, and the cure of the valvular lesions. Taking into account the gravity of this complication, a close clinical, electrocardiographic and echocardiographic surveillance of all infectious endocarditis is necessary.
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A bidimensional cardiac sonogram was performed in 152 consecutive patients with in 24 hours after hospitalization in the intensive care unit for acute myocardial infarction, in order to evaluate the contribution of this technique to the diagnosis, determination of early complication and the prognosis. For this study, the left ventricle was divided in 10.segments. For each segment, systolic mobility as well as thickness were evaluated. It was possible to obtain a proper recording in 134 patients. Abnormal left ventricular kinetics (at least 1 segment) is present in all anterior transmural infarctions with, in 90 p. cent of the cases, a concordance between electrical and sonographic localization and in 89 p. cent of inferior between electrical and sonographic localization and in 89 p. cent of inferior only present in 65 p. cent. Abnormal kinetics is only present in 65 p. cent of non transmural infarctions. In 15 patients with clinical infarction without any electrical sign, the cardiac sonogram permitted to make the diagnosis and establish the localization of the infarction. In 46 p. cent of the cases, a left ventricular asynergy was observed at a distance of the necrosed area. In these patients, the mortality and cardiogenic shock rates during hospitalization were higher than for patients who did not present these abnormal findings (p less than 0.01). In conclusion, bidimensional cardiac sonography is a very specific diagnostic tool, permitting an early prognosis and able to detect early complication, especially of pericardial and mechanical nature.
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The tolerance and efficacy of propafenone were studied in cases of chronic ventricular extrasystoles of the elderly (age greater than 70 years). Only patients presenting more than 1,000 extrasystoles per day and requiring a treatment, were included in this study. Patients presenting non-compensated cardiac insufficiency, hypotensive patients, patients with conduction disorders without pacemakers as well as patients presenting a severe renal or hepatic insufficiency, were excluded. After making sure that the rhythm disorder was chronic, a control Holter was performed, then, 600 mg of propafenone per day, in 3 doses were prescribed for 5 days. On the 5th day, a Holter was performed as well as a blood propafenone level. Some patients received then 900 mg per day with a new Holter and plasma propafenone titration on the 10th day. 11 patients were studied in this fashion. The tolerance to 600 mg was good in 10 out of 11 cases. The efficacy, appreciated by the decrease of the number of isolated ventricular extrasystoles (-69%), doublets (-95%), triplets (-98%) and salvos of ventricular tachycardias (-100%), was excellent in 6 cases, average in 2 cases and mediocre in 3 cases. Increase of the dosage to 900 mg does not improve significantly the anti-arrhythmic efficacy while the side effects seem more frequent. It is not possible to establish a relationship between plasma concentrations and efficacy. At a dosage of 600 mg per day, propafenone is therefore effective in the treatment of ventricular extrasystoles in elderly patients and its tolerance is good. Higher doses are not advisable as they seem much less well tolerated without any additional advantage.
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Reciprocal ST segment changes are frequent during acute inferior myocardial infarction, yet their significance remains controversial. In order to investigate the implications of these changes, the ECG obtained on admission for 83 patients with acute inferior myocardial infarction was compared with the clinical course and the results of angiographic and coronary arteriographic studies performed an average of 3 weeks after the onset of symptoms. Group 1 consisted of 59 patients with at least 1 mm of horizontal on downsloping ST segment depression in at least 1 of leads V1 to V4. Groups 2 consisted of 24 patients without precordial ST depression in this area. Group 1 patients were generally older than group 2 patients (59.6 +/- 6.4 versus 54 +/- 5.3 yr, P less than 0.01) had higher total creatine kinase (CK) levels and MB fractions (1835 +/- 940 versus 875 +/- 305, P less than 0.01, 269 +/- 102 versus 95 +/- 35 for MB fraction) and more complications during the hospital course (80% versus 38% P less than 0.01) and greater left ventricular dysfunction (ejection fraction 52.2 +/- 6% for group 1 versus 59.2 +/- 7% for group 2; cardiac index 2.75 +/- 0.41 min-1 m-2 for group 1 versus 3.25 +/- 0.31 min-1 m-2 for group 2 P less than 0.005). No difference was observed on biplane angiography as far as left ventricular wall kinesis was concerned.(ABSTRACT TRUNCATED AT 250 WORDS)
The aim of this study was to compare the efficacy and safety of enalapril and a combination of a thiazide diuretic (altizide) and a diuretic that reduce potassium excretion (spironolactone), in patients presenting moderate essential hypertension. The four-month, double-blind study of two parallel groups involved 20 patients (12 males, 8 females) of mean age 54 years. All patients first received placebo for 15 days. Subsequently, 10 patients received 20 mg enalapril per day and 10 patients 15 mg altizide combined with 25 mg spironolactone in the same tablet. Blood pressure was measured every five minutes for 30 minutes with an automatic apparatus (Dynamap 845), before administration of placebo, before treatment and one, two and three months after treatment. There was no significant change of pulse rate with enalapril or with the diuretic combination. Both treatments produced an identical significant drop in systolic pressure. On the other hand enalapril seemed more efficacious in reducing diastolic pressure at the fourth month: respective pressures 98.2 +/- 13.3 mmHg and 81.0 +/- 8.5 mmHg (p less than 0.005) with enalapril, 98.6 +/- 7.4 mmHg and 86.0 +/- 6.1 mmHg (p less than 0.001) with the diuretic association (17% versus 12%, p less than 0.05). Safety was good with both medicinal preparations and the few side-effects noted did not necessitate withdrawal of treatment.
The aim of this work is the evaluation of the hemodynamic effects during the 24 hours following a single administration of a new arterial vasodilator, cadralazine, in 12 patients whose mean age is 66 years and who present severe cardiac insufficiency. A clinical and hemodynamic examination was made before administration of the medicine in 3 doses at 12 hour intervals in order to check the stationary state of the patients, and then at 1 h, 2 h, 4 h, 6 h, 8 h, 12 h, 20 h and 24 h after 30 mg, and then 60 mg of cadralazine. We did not observe any significant change in cardiac frequency, nor in the systolic arterial pressure nor in the diastolic arterial pressure of the pulmonary artery, after either 30 mg or 60 mg. On the other hand, with 30 mg of cadralazine we observed a significant increase of the cardiac index, with a maximum between the 6th and 8th hour (1.58 +/- 0.51 l.min-1.m-2 before treatment to 2.66 +/- 0,75 l.min-1.m-2 8 hours after, p less than 0.001) and a fall of total systemic resistance which declined from 2,478 +/- 421 dyn.s-1.cm-5 before treatment to 1,449 +/- 369 dyn.s-1.cm-5, p less than 0.001, 8 hours after, as well as an increase in the power of the left ventricule (from 2.80 +/- 0.8 before treatment to 4.73 +/- 1.2 kg/min 8 hours after, p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)
Following insertion of a Leveen's valve after surgical portocaval anastomosis, a male patient with alcoholic cirrhosis developed dyspnoea with hypoxaemia. An interstitial syndrome was present in the lower lobes. Other findings were: polycythaemia (Hb 20 g/100 ml), subnormal spirometric values, decrease in CO transfer capacity, normal pulmonary compliance, absence of intracardiac shunt and pulmonary arterial hypertension and absence of bronchial or alveolar lesions on a surgical lung biopsy. Blood gas measurements and radioisotope explorations led to the conclusion that the patient had an anatomical shunt predominant in the lower parts of the lungs, associated with a shunt effect and a transfer disorder. The anatomical shunt was due to pulmonary arteriovenous microfistulae, some of which were visualized by superselective angiography. Catheterization of the portocaval anastomosis eliminated any shunt between the portal system and the pulmonary veins.
The aim of this paper is to study the clinical and haemodynamic tolerance of intravenous diltiazem in a bolus dose of 10 mg followed by an infusion of 360 mg over 24 hours in 12 patients in the acute phase of myocardial infarction. We did not observe any significant modification in the heart rate or in the pulmonary artery diastolic pressure. The mean blood pressure decreased from 111.5 +/- 11.8 mmHg to 92.8 +/- 12.7 mmHg (p less than 0.001) after a 24 infusion. The cardiac index increased from 2.34 +/- 0.62 1 X min1 X m-2 to 3.05 +/- 0.95 1 X min-1 X m-2 (p less than 0.05) and the systemic vascular resistance decreased from 2 150 +/- 640 dyn. s.cm-5 to 1 403 +/- 308 dyn.s.cm-5 (p +/- 0.005). Three patients presented a rise in the pulmonary artery diastolic pressure of more than 30 mmHg and in one of these patients, the diltiazem had to be stopped. These three patients all had a high initial pulmonary capillary pressure (greater than 18 mmHg). The drug was well tolerated clinically. On electrocardiography, four patients presented conduction disorders, all of which regressed when the diltiazem was stopped (a 3rd degree atrioventricular block with narrow QRS complexes, a Luciani-Wenckebach type of 2nd degree atrioventricular block and two cases of 1st degree atrioventricular block. Overall, intravenous diltiazem was well tolerated in terms of clinical and haemodynamic parameters in these patients in the acute phase of a myocardial infarction, provided the left ventricular filling pressure was not excessively elevated.(ABSTRACT TRUNCATED AT 250 WORDS)