[Dipyridamole stress myocardial scintigraphy].
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Biomedical subjects
Publications and source records attributed to M Benomar.
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One hundred and eighty-four patients underwent complete lipid analysis (total cholesterol, HDL and LDL cholesterol, triglycerides, apolipoproteins A1 and B, lipoprotein (a)) and coronary angiography, in order to evaluate the discriminant value of the lipoprotein (a). Subjects with non-significant coronary stenoses (< 50% of the lumen) were used as a control group (n = 84). The others were considered to be pathological. The total cholesterol, HDL cholesterol and triglycerides were measured by an enzymatic colorimetric method. The LDL cholesterol was calculated by Friedewald's formula. The apolipoprotein A1 and B were measured by immunoturbidimetry and the lipoprotein (a) by an Elisa. The results showed a relationship between the different lipid levels, especially between high lipoprotein (a), and the severity of the coronary disease. A quantitative and qualitative study showed no significant influence of the other risk factors on the mean lipoprotein (a) level. Gender and age had no influence. Therefore, the higher the lipoprotein (a) level, the greater was the coronary risk, independently of the other associated risk factors.
The authors report the case of a young patient with a tumour of the right atrium and right ventricular outflow tract without visceral complications but with multiple muscular and skin localisations. The diagnosis of tuberculosis was made on biopsy of a suppurating skin lesion. The diagnosis of tuberculosis was made on biopsy of a suppurating skin lesion. Anti-tuberculosis treatment resulted in regression of these tumours, especially the cardiac lesions, confirmed by transoesophageal echocardiography.
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The authors present the case of a 30-year-old woman admitted to hospital for investigation of a systolodiastolic murmur. Assessment revealed a fistula between the trunk of the left coronary artery and the pulmonary artery, with an aneurysm on the left anterior descending artery (LAD), associated with an intercoronary anastomosis between the left conus artery and the LAD. Thallium myocardial scintigraphy demonstrated reversible decreased uptake in the anterolateroapical region. Simple coronaro-pulmonary fistulas are a rare disease. The positive diagnosis is suggested by echocardiography and confirmed by coronary angiography. The clinical course is generally favourable, except in the presence of complications such as aneurysm, heart failure or coronary insufficiency. This case raises the difficult problem of the operative indication in these young, usually asymptomatic patients.
The authors report two cases of severe myocardial ischaemia with healthy coronary arteries associated with mitral valvular prolapse (MVP). The first case was a 43-year-old woman treated with beta-blockers following the discovery of MVP. This patient was admitted to hospital six months later with persistent chest pain in a context of cardiogenic shock. The response to treatment was rapid and spectacular. The second case was a 44-year-old hypertensive smoker man in whom assessment of chest pain revealed several signs of myocardial infarction as well as MVP. This rare combination of MVP and myocardial ischaemia raises pathophysiological as well as therapeutic problems.
Ten cases of right-sided infective endocarditis (IE) were recorded in a retrospective study over a 5 year period (1984-88). In 8 cases, IE complicated known congenital heart disease. One patient was followed up for rhumatic valvular disease and in the remaining case, IE seemed to have occurred on a normal valve. The inclusion criteria were based on the clinical signs: prolonged pyrexia, the finding of a new murmur or a change on cardiac auscultation, and eventually, the occurrence of a complication (7 cases). The commonest complications were right ventricular failure and pulmonary embolism. A portal of entry was found in 5 cases: dental infection in 3 cases, osteomyelitis in 1 case and an abscess on the right leg in 1 case. Blood cultures were positive in 5 cases and grew a staphylococcus aureus on each occasion. Two-dimensional echocardiography showed vegetations in 9 cases. The short-term outcome was satisfactory. There were no fatalities and 5 patients underwent surgery.
A 39-year old patient presented with small, sudden hemoptyses and a diagnosis of pulmonary tuberculosis was made on radiographic pleural and parenchymatous lesions but without bacteriological confirmation. Two years later, the patient was admitted to hospital following severe hemoptysis. Echocardiography revealed the presence of a tumour in the right ventricular outflow tract. At surgery, nodules were also resected from the superior vena cava. Histological examination of the surgical specimens suggested that the tumour was an angiosarcoma. Six months later, the patient returned complaining of a painful swelling in the left iliac fossa. Immuno-histochemical analysis of the cardiac and abdominal tumours finally concluded that it was in fact a malignant non-Hodgkinian lymphoma.
The authors report a case of isolated left ventricular capillary haemangioma, diagnosed after chest X-ray during a routine medical check-up showed a deformation of the left heart border. Echocardiography showed a solid well circumscribed tumour. Its vascular origin was confirmed at coronary angiography. Myocardial biopsy performed after left thoracotomy confirmed the histological diagnosis. The authors review the medical literature of this condition in the light of this rare finding.
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A case of pericardial hemolymphangioma revealed by palpitations is reported. X-ray films of the chest provided a diagnosis of mediastinal tumour. Full evaluation was performed using echocardiography, computerized tomography of the mediastinum, coronary arteriography and cardiac ventriculography. The tumour could be removed in toto. Pericardial hemolymphangioma is a rare benign vascular tumour. It is often discovered accidentally during examinations for non-suggestive cardiac functional disorders. The threat of compression or invasion of adjacent structures and that of hemopericardium by bleeding make surgical excision mandatory.
Thirty-five patients with moderate or severe valvular pulmonary stenosis underwent percutaneous transluminal valvuloplasty (PTV). The average age of the patients was 12 years (range 4 to 34 years). Sixty per cent were under the age of 10, 20 p. 100 were between 10 and 17 years old and 20 p. 100 between 18 and 34 years old. Systolic right ventricular pressures were greater than the pressures in the systemic circulation in 22 cases. The right ventricular-pulmonary artery pressure gradient was greater than 50 mmHg in 29 patients and less than or equal to 50 mmHg in the other 6 patients. The diameter of the balloon of the dilation catheter varied from 12 to 20 mm in 31 PTV; in the other 4 cases two dilating catheters were used simultaneously to dilate the pulmonary valves. The tolerance of PTV was generally good and the results were satisfactory: right ventricular pressures (RVP) fell from 140 +/- 45 to 77 +/- 25 mmHg (p less than 0.001); the RV-PA pressure gradient fell from 82 +/- 40 to 32.4 +/- 15 mmHg (p less than 0.001) and the ratio of RVP to systemic pressure from 1.2 +/- 0.4 to 0.65 +/- 0.2 (p less than 0.01). Clinical and haemodynamic reevaluation in 19 patients 4 to 16 months after PTV (mean 8.5 +/- 2 months) showed that RVP, RV-PA pressure gradients and RVP/systemic pressure ratios had significantly decreased respectively from 78 +/- 30 to 52 +/- 14 mmHg (p less than 0.001), from 27.7 +/- 7.7 to 21.8 +/- 7.3 mmHg (p less than 0.02) and from 0.6 +/- 0.2 to 0.4 +/- 0.1 (p less than 0.001). Pulmonary valvuloplasty is well tolerated, safe and may reduce the number of patients requiring surgical valvotomy.
Percutaneous mitral commissurotomy using balloon catheters was attempted in 17 patients (16 of whom were women) with rheumatic mitral valve stenosis. The patients' age ranged from 15 to 34 years (men 21 years). Functionally, 15 of the patients were in stage III of the New York Heart Association classification, and 2 were in stage II. Sinus rhythm was present in all cases. Slight mitral regurgitation was noted in 2 cases, associated with mild aortic disease in one of them; 3 other patients presented with slight aortic regurgitation. In all 17 cases the mitral stenosis was tight, uncalcified, with flexible valves and little or no alteration of the subvalvular system. One single balloon catheter was used in 11 patients and 2 balloon catheters were introduced simultaneously in the remaining 6 patients. The new therapeutic method was successful in all patients. Following valvuloplasty, the mean transmitral gradient was reduced from 25 +/- 3 to 11 +/- 2 mmHg (P less than 0.001), the mean capillary pressure fell from 26.8 +/- 7.1 to 13.5 +/- 3.7 mmHg (P less than 0.001) and the cardiac index increased from 3.3 +/- 1 to 4.2 +/- 1.2 l/min/m2 (P less than 0.001). The mitral valve area, measured by two-dimensional echocardiography, increased from 1.0 +/- 02 to 2.1 +/- 0.3 cm2 (P less than 0.001). The mitral valve regurgitation observed in 2 patients before valvuloplasty was aggravated, although still moderate, in one of them and remained stable in the other.
In reporting a case of haemangiosarcoma of the right atrium the authors emphasize the problems encountered in the diagnosis of primary tumours of the heart. The patient was a 50-year old woman who complained of digestive disorders and palpitations. Physical examination showed signs of right heart failure associated with a systolic murmur on the right side of the sternum. ECG gave normal results. Echocardiography displayed a pouch with liquid ultrastructure communicating with the right atrium. Angiography confirmed the presence of a cavity with irregular borders communicating with the right atrium. Coronary arteriography showed an abnormal disorderly distribution of the right coronary artery branches with newly formed vessels extending toward the tumour. At exploratory thoracotomy a large liquid tumour was found which bled at the slightest touch and was attached to the mediastinum and the right pericardium. The pleura and the lung contained several nodules of the same venous colour as the mother tumour. Extemporaneous biopsy and pathological analysis were in favour of a haemangiosarcoma. The patient died a few days after the thoracotomy.
Two cases of primary cardiac tumour are reported. The first was that of a 16 year old girl investigated after the detection of a systolic murmur on routine examination. The clinical signs suggested a diagnosis of pulmonary stenosis. The second case was that of a 36 year old man admitted to hospital for right ventricular failure. Echocardiography revealed right ventricular tumours in both cases and also indicated their size, form, mobility and site of implantation. The outcome of the first case, a fibromyxoma, was favourable with no detectable recurrence after one year. In the second case, the patient unfortunately died of cardiogenic shock in the immediate preoperative period. These two cases emphasise the value of echocardiography in the diagnosis of isolated right ventricular tumours, especially considering the difficulty of clinical diagnosis and the risks of angiocardiography.
From March 1969 to March 1984, 89 children aged 2 to 12 years (mean 8.3 +/- 2.5) with acquired mitral valve incompetence underwent mitral repair using Carpentier's techniques. There were 84 cases of rheumatic valve disease, four cases of endocarditis, and one case of Barlow's syndrome. Valve dysfunction was classified into three types: type I (normal leaflet motion), five patients; type II (prolapsed leaflet), 74 patients; and type III (restricted leaflet motion), 10 patients. Cumulative follow-up was 546 patient/years. At 10 years, 90% of the patients were still alive, with an incidence of valve-related death of 5.5%; 98% of the patients were free of thromboembolism, 78% were free of reoperation, and 69% of the patients were free of any complications related to valve repair. We conclude that whenever feasible (92% of the cases in our experience), mitral valve repair using valvuloplasty techniques is the preferred procedure in the surgical treatment of acquired mitral valve incompetence in children.
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Sixty-four patients with one or more bioprostheses were reoperated between 1970 and 1982. Reoperation was performed for degenerative lesions in cases (48%), for aseptic periprosthetic leaks in 18 cases (28%), for infectious lesions in 13 cases (21%) and for thrombosis in 2 cases (3%). Degenerative and infectious lesions were commoner in aortic bioprostheses whilst periprosthetic leaks were commoner in mitral bioprostheses. The average interval between operations was 38 months. This was shorter in patients reoperated for mechanical problems (6 months) than those with infections (28 months) or degenerative (5 years) complications. At reoperation 14 prostheses were reinserted and 50 were replaced. The global hospital mortality was 21% (14 deaths). The mortality was related to the surgical indication: mechanical lesions (11%), degenerative lesions (16%), infectious endocarditis (38%), thrombosis (100%). The mortality rate also varied with time (36% during the period 1970-1978 and 18% during the period 1979-1982). This improvement was related to two factors: the use of cardioplegic solutions for myocardial protection and earlier recognition of surgical indications before the onset of irreversible haemodynamic complications. When choosing a valvular prosthesis, the mortality of reoperation for degenerative changes is the only disadvantage of the bioprosthesis which is silent, rarely complicated by thromboembolism and which does not require anticoagulant therapy for life. The mortality has decreased with time and will continue to fall if the indications for reoperation are based on stethacoustic, electrical, radiological and echocardiographic criteria of valvular dysfunction and not on the presence of overt cardiac failure as is still often the case.