Biomedical subjects
Publications and source records attributed to M Desnos.
We report one case of successful cardiomyoplasty in a 21-year-old male and its beneficial effects as assessed by clinical examination, Doppler echocardiography, phonocardiography, haemodynamic and angiographic evaluation at 1 year. Long-term efficacy of this procedure on left ventricular function was confirmed by these techniques.
Four cases of hypertrophic obstructive cardiomyopathy diagnosed on clinical, phonomechanographic, echocardiographic and haemodynamic criteria progressing to dilated cardiomyopathy are reported. This evolution was observed over a number of years (up to 20 years) and was accompanied by a clinical aggravation in all cases with 2 deaths and atrial fibrillation in 3 of the 4 cases. The signs of intraventricular obstruction [systolic murmur, bulge on the carotid pulse tracing, systolic anterior motion of the mitral valve (SAM) and intraventricular pressure gradient] disappeared as the left heart chambers dilated with a reduction in ventricular wall motion and parietal thinning but no change in myocardial mass.
Dynamic cardiomyoplasty is a surgical operation aimed at compensating for a loss of substance or a severe deficiency of the left ventricular myocardium by implanting around the heart the latissimus dorsi muscle the contraction of which, synchronous with that of the ventricles, acts on the heart in the manner of a massage or milking. The operation, which in its present form is recent, consists of applying Onto the heart, or wrapping that organ with, a skeletal muscle that keeps its neurovascular supply and its high insertion, and of installing the appropriate electrodes and a pacemaker. We report the haemodynamic data collected in 3 patients operated upon for severe cardiac failure 13, 8 and 9 months ago respectively and who are now in NYHA functional stages I and II. During 1/1 stimulation of the latissimus dorsi systolic pressures remain unchanged while diastolic pressures rise; cardiac output increases satisfactorily in two of the patients (cases No. 1 and 3) and is unmodified in the third one (case No. 2). We conclude that cardiomyoplasty seems to give favourable results but its future and indications remain to be determined.
The "dynamic" left ventricular outflow obstruction syndrome, which is found in 4.5 to 11 p. 100 of patients who underwent mitral valve repair by Carpentier's technique, seems to be due to the association of two different sets of circumstances. The first set is anatomical; the syndrome is thought to result from the implantation of a semi-rigid valve ring, from the excessive length of the mitral valve system in relation to the size of the ventricular cavity, and from excessive correction of mitral regurgitation with subsequent excessive reduction in caliber of the left ventricular outflow tract, change in the interrelation between outflow tract and ventricular filling and strongly anterior position of the mitral valve. The second set is functional; it is due to a more than 20 p. 100 reduction in caliber of the left ventricular outflow tract on the one hand, and to a more than 2.5 m/s increase in blood flow velocity on the other hand. These two phenomena may be produced by a decrease in left ventricular volume as a result of hypovolaemia, tachycardia or more rapid circulation. Treatment of the syndrome consists of correcting the associated abnormalities by prescribing a diet with a normal sodium content, together with an appropriate anti-arrhythmic agent and a beta-blocker.
Agenesis of the left main coronary artery is a congenital condition the prognosis of which is reputed to be good in adults, provided no associated heart disease is present. The first case reported here illustrates the benign character of the anomaly. In contrast, the second case shows that when associated with proximal atheromatous stenosis of the single right coronary artery the anomaly may have catastrophic consequences. The anatomical variants and morbid associations of left main coronary artery agenesis are described.
Among 226,464 ambulatory subjects who underwent medical check-ups over a 15-year period, 270 were found to have Wolff-Parkinson-White syndrome (1.2 case in 1,000). The syndrome was more frequent in men (181 cases, 1.4 p. 1,000) than in women (89 cases, 0.9 p. 1,000). 222 subjects were aged from 20 to 49 years (1.4 p. 1,000) and only 48 were between 50 and 80 years of age (0.7 p. 1,000). 197 subjects were re-evaluated: 119 (60.4 p. 100) complained of palpitations and 78 (39.6 p. 100) were asymptomatic. Palpitations began at all ages, even after 50 years, and usually proceeded in short attacks lasting a few seconds or minutes, with a mean recurrence rate of 5 attacks per annum (76.4 p. 100). This constant pattern sometimes was interrupted for months or years. Conversely, in a minority of cases (23.5 p. 100) an unexpected accentuation occurred which lasted for hours or days. As years went by, palpitations tented to decrease and disappear. The pre-excitation area and its degree of fusion with the normal ventricular activation had no influence on the origin and frequency of palpitations. In contrast, sustained tachycardia seemed to be more frequent in cases with lateral and posterior left pre-excitation. Among 270 subjects with pre-excitation syndrome, 7 died including 4 whose death was not due to a cardiac disease, 2 who died suddenly and 1 who succumbed to ventricular tachycardia after a road accident. None of these patients had an associated heart disease. These last 3 cases might contribute to alter the usually favourable prognosis of Wolff-Parkinson-White syndrome.
The authors report a case of intracoronary rupture of the tip of a guidewire used for angioplasty. They discuss its mechanism and management. The hazards involved in re-using coronary dilatation material are underlined.
Five fluoro-uracil (5-FU) is a cytotoxic drug which has been extensively used for chemotherapy since 1957. Ischaemic heart disease resulting from its administration is rare. Spontaneous angina during infusions of 5-FU was observed in two patients with electrocardiographic changes suggesting coronary spasm. After treatment, clinical examination, electrocardiogram, echocardiogram, stress test, coronary angiography with left ventriculography were all normal. An Ergonovine test was performed in one patient but failed to elicit coronary spasm. In the other patient, intravenous trinitrin and diltiazem were ineffective in preventing the ischaemic changes. A review of the literature is presented (51 cases). The pathophysiology of 5-FU-induced ischaemic heart disease is not fully understood. In 9 cases, coronary angiography was normal and coronary spasm was suggested as a possible cause. However, antispastic drugs are usually ineffective. It has been shown experimentally that 5-FU has a direct toxic effect on the myocardium.
The sinus disease in children with "healthy hearts" is exceptional, and has never been documented by tracing of the sinus node. We are reporting two cases of two children, aged 4 and 14 years. An electrophysiological exploration with measurement of the direct activity of the sinus node, illustrates in one case the mechanism of sinus dysfunction. A review from the literature and our cases specifies some of the characteristics of this disease: 1) there are two forms: sporadic (case n. 1) 59 published cases, and familial (case n. 2) 28 published cases in 13 families; 2) the familial forms have a dominant autosomic transmission with variable penetration; 3) the disease may occur during the first days of life, suggesting a congenital origin (from the pathology findings, this disease may be one of the causes of the unexplained sudden death syndrome in infants; 4) association to atrio-ventricular conduction disorders and atrial and ventricular rhythm disorders; 5) frequent indication of stimulators, emphasizing the severity of this disease with a more severe course in sporadic forms (7 deaths in 59 cases).
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The authors report a case of percutaneous dilatation of a coronary artery performed immediately after a mild myocardial infarction and complicated by occlusive thrombosis without dissection, despite a presumably effective anticoagulant treatment. A second dilatation resulted in rapid recanalization of the artery, but recurrent thrombosis developed at the site of dilatation. The thrombotic process was controlled with an intracoronary infusion of urokinase and higher doses of intravenous heparin, but only after a long delay (80 minutes). This case suggests that in similar circumstances one must wait long enough before referring the patient to a surgical unit for emergency aorto-coronary bypass.
None of the medical treatments of hypertrophic cardiomyopathy is perfect. In the present study conducted on 11 patients with hypertrophic cardiomyopathy in whom the usual treatments were either ineffective or badly tolerated, the haemodynamic effects of propafenone administered intravenously were investigated. The drug was injected centrally in doses of 2 mg/kg over 10 minutes, then by continuous intravenous infusion of 1.5 mg/min during 30 minutes. Various parameters were recorded before and after propafenone treatment by right and left cardiac catheterization. This anti-arrhythmic drug, which has beta-blocking and amiodarone-like properties, reduced left intraventricular obstruction but had no beneficial effect on diastolic function. The baseline and induced left intraventricular gradients were reduced from 30.4 to 17.7 mmHg and from 74 to 43 mmHg respectively. Diastolic function values showed a fall in dp/dt min from 1470 to 1307 mm/sec and an increase in T value from 0.066 to 0.084. The use of propafenone in hypertrophic cardiomyopathy must be accurately determined by long-term oral studies.
One hundred and sixteen patients (mean age 46 years) with dilated cardiomyopathy documented by haemodynamic investigations and angiography with normal coronary arteriography were followed up for a mean period of 29 +/- 19 months. During that period, 36% of the patients died after a follow-up of 30 +/- 20 months. The actuarial death rates were 15% at 2 years, 45% at 6 years and 60% at 10 years. The main factors predictive of survival at 10 years were the clinical and haemodynamic markers of left heart failure. The death rate was multiplied by 1.6 in patients in stages III or IV of the NYHA classification (83% vs 51%, p less than 0.01), by 2.6 in patients with left ventricular end-diastolic pressure above 15 mmHg (73% vs 29%, p less than 0.01), by 2.2 when the indexed end-diastolic volume rose above 200 ml/m2 (75% vs 35%, p less than 0.01), by 2.2 when the left ventricular ejection fraction was below 40% (75% vs 35%, p less than 0.05) and by 2.6 when angiographic mitral valve regurgitation was present (75% vs 34%, p less than 0.01). The death rate at 9 years was 2.3 times higher in patients with left bundle branch block (72% vs 36%, p less than 0.05). A cardiothoracic index over 0.60 proved to be of poor prognosis at one year (death rate: 19%). While alcoholism played no part in the prognosis, the death rate in smokers was consistently higher than in non smokers (56% vs 32% at 6 years, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Between January, 1977 and December, 1980, 128 porcine bioprostheses were implanted in 109 European patients hospitalized at the Boucicaut hospital, Paris: 47 were aortic valve replacements (AVR), 43 mitral valve replacements (MVR) and 19 dual valve replacements (DVR). The operative mortality rate was 11% (12 patients): MVR 21%, AVR 6.4%, DVR 0%. 3 patients were lost sight of. The mean follow-up period was 59.3 months (3-96 months). The overall survival rate at 6 years, including early deaths, was 74.4 +/- 8%: MVR 66.1 +/- 15%, AVR 84.9 +/- 10%, DVR 68.6 +/- 20%. Eighteen late deaths were reported (3.7% patient-years [PY]), 3 of which were due to the valve (0.6% PY). The probability at 6 years of escaping death due to the valve was 96.3 +/- 4%: MVR 96.9 +/- 4%, AVR 100%, DVR 87 +/- 17%. Complications associated with the valve were observed in 17 patients (3.5% PY); they were: degeneration in 2 (0.8% PY), thromboembolic accident in 2 (0.4% PY), haemorrhagic accident in 4 (0.8% PY), endocarditis in 5 (1% PY) and simple disinsertion in 2 (0.4% PY). The probability at 6 years of escaping a complication due to the valve was 80.7 +/- 10%: MVR 90.4 +/- 13%, AVR 81.8 +/- 13%, DVR 55.3 +/- 35%. The probability at 6 years of escaping death and re-operation due to the valve was 88.5 +/- 8%: MVR 96.0 +/- 6%, AVR 87.9 +/- 11%, DVR 60.2 +/- 37%. This study and those already published show that compared with mechanical prostheses, bioprostheses clearly reduce the incidence of thromboembolic and haemorrhagic accidents.(ABSTRACT TRUNCATED AT 250 WORDS)