Abstract: Echocardiography is a key tool in the diagnosis of infective endocarditis. Although transthoracic echocardiography is the first step in the work-up, transoesophageal echocardiography is mandatory for the evaluation of the exact extent of the infectious process. Indeed, perivalvular abscess can fistulate towards different heart chambers, leading sometimes to critical clinical situations.
Abstract: Heart failure and atrial fibrillation are the main problems in general cardiology. Our therapeutic reflections summarize new ideas in the treatment of theses pathologies but we will not forget importance of PCI. All these therapies have proven now the clinical benefit but also reduction in more morbidity and mortality. Cardiac resynchronisation therapy has shown promising results. The art of medicine to develop will be to better identify the patients benefiting from this therapy. Interventional cardiology is focusing on the acute coronary syndrome. Not only rapid intervention but also the stent technology allow significant modification of endothelial tissue reaction and therefore improve the general benefit for the patient.
Abstract: Lyme disease is the most common tick-borne disease in Europe and in the United States. In comparison to dermatological, neurological and rheumatological manifestations, heart disease is quite rare. Atrioventricular heart block is nevertheless the most frequent cardiological manifestation. We hereby report the case of a patient with high degree heart block due to Lyme disease. We focus on the electrocardiographical evolution during antibiotic therapy, as well as on microbiological and diagnostic aspects. Lyme disease is a rare cause of conduction disturbances but it is treatable and potentially reversible.
Abstract: Elective left main (LM) stenting is increasingly performed as a valuable alternative to coronary artery bypass grafting. Nevertheless, clinical data are limited to registries, and randomized trials have not been published. Intravascular ultrasound (IVUS) has been recognized as an accurate tool for assessing optimal stent deployment. We hereby report the usefulness of IVUS in defining the interventional strategy in four consecutive patients presenting with severe, symptomatic ostial LM disease, and this in the era of drug-eluting stents. The first two patients were treated by a short drug-eluting stent for a critical LM stenosis as IVUS demonstrated a reference diameter < 3.7 mm. The third patient had a larger reference diameter and was treated with conventional stenting with optimization of the result by IVUS. IVUS was particularly helpful in all patients to confirm accurate stent placement in relation to the LM ostium and bifurcation. In another patient, based on IVUS findings, surgery was preferred. This patient with diabetes as a risk factor presented with comparable angiographic features. IVUS, however, showed diffuse disease without any healthy reference segment in the LM. All stented patients are asymptomatic at 15 +/- 7 months follow-up with negative stress testing. The present observation indicates that IVUS is an essential tool for strategic selection and to optimize percutaneous coronary intervention for LM disease.
Abstract: The therapeutic acquisition to be retained for 2004 are: 1. The elderly patients with heart failure also should receive beta blocker treatment. The correction of anaemia, aggravating factor in heart failure, improves symptoms and survival of the patient. 2. It remains to prove that the treatment of sleep apnea, which seems to be an additional factor for mortality in cardiovascular diseases, is able to reduce the risk. 3. The interventions in the endocanabinoïd system which regulates weight and metabolic processes might be a promising new therapeutic acquisition. 4. Prevention of coronary disease with lipid lowering drugs is still a major topic, and the trend goes the lower the better. The problems observed with Rofecoxybe and other drug interactions reminds us to be conscious when prescribing multiple drugs. 5. The implantable defibrillator seems to be a life insurance in the event of ventricular fibrillation. However, it is not so easy to identify the patient who might really benefit.
Abstract: About a quarter of the adult population is known to have a patent foramen ovale, rarely accompanied by the presence of an interatrial septal aneurysm. A patent foramen ovale is found in more than 40% of patients younger than 60 years who had a cryptogenic ischemic stroke. Clinical and echocardiographic parameters allow the identification of patients at high risk of recurrence after a first cryptogenic stroke even if treated with Aspirin. A multidisciplinary approach allow the selected patients to benefit of a correction of their cardiac anomaly with promising long term results.
Abstract: OVERVIEW: Arterial hypotension during stress echocardiography with Dobutamine (ESD) is an occasional complication with no prognostic value, but it sometimes necessitates termination of the investigation. The present study had the aim of elucidating the mechanism responsible for hypotension during ESD and proposing one or several markers for patients at risk for this complication. METHOD: One hundred and twenty consecutive patients referred for stress echocardiography (Dobutamine or cycloergometrine) were analysed. Arterial hypotension induced by Dobutamine was defined as a fall of more than 30 mmHg compared to the arterial pressure before the test or following the preceding level of Dobutamine. Concentric left ventricular hypertrophy (LVH) was defined as a left ventricular mass > 125 g/m2. RESULTS: Among the 89 patients undergoing ESD, 32 (35%) had LVH, 9 of whom (28%) had arterial hypotension, prompting termination of the examination in 4 patients. Among the 57 patients (65%) without LVH, only 2 (3%) had hypotension. All patients with LVH had normal left ventricular function at rest and excellent contractility under stress, with no sign of ischaemia. None of the 31 patients, 5 of whom had LVH, who underwent the test with cycloergometrine had hypotension. CONCLUSION: Hypotension occurring during ESD affects patients more often with LVH (p < 0.001) and excellent systolic function. We postulate that the vigorous contraction of the left ventricle with Dobutamine produces excessive stimulation of the cardiac mechanoreceptors inducing a reflex hypotension. LVH is therefore a marker for patients at risk of hypotension and effort echocardiography is an excellent alternative to this investigation.
Abstract: IVUS is considered as the most accurate tool for the assessment of optimal stent deployment. Direct stenting has shown to be a safe, efficient, and resource-saving procedure in selected patients. In a prospective 1-month feasibility trial, a new combined IVUS-coronary stent delivery platform (Josonics Flex, Jomed, Helsingborn, Sweden) was evaluated during direct stenting in consecutive patients considered eligible for direct stenting. The feasibility endpoint was successful stent deployment without any clinical adverse event, while the efficacy endpoint was strategic adaptation according to standard IVUS criteria for optimal stent deployment at the intermediate phase (after a result considered angiographically optimal) and at the end of the intervention (after optimization according to IVUS standards). A total of 16 patients were successfully treated with this device without any major clinical complication. At the intermediate phase, optimal stent deployment was achieved in four patients only, while at the end only one patient had nonoptimal IVUS stent deployment. In particular, the minimal in-stent cross-section area increased from 6.3 +/- 1.2 to 8.3 +/- 2.5 mm(2). These preliminary data demonstrate the feasibility of direct stenting with a combined IVUS-stent catheter in selected patients and confirm the results from larger randomized trials on the impact of IVUS on strategic adaptations during coronary stent placement.
Abstract: BACKGROUND: With the advent of second harmonic imaging in echocardiography, microbubbles have been observed during opening and closure of mechanical prosthetic valves. The single phenomenon of cavitation, an extremely short event described in the literature, cannot explain the persistence of microbubbles during several hundred milliseconds. Therefore, in vitro we reproduced two distinct phenomena created by a local depression occurring during the closure and/or opening of prosthetic valves: Cavitation and degassing. METHODS: We used a water circuit system enriched with CO(2) that passes through a Venturi tube in order to create variable pressure gradients. Three types of observations were performed: (1). the dimensions of the bubbles as a function of pressure, (2). calibration of the echocardiograph, and (3). comparison and illustrations of the difference between bubble formation by cavitation (vaporization) and degassing (liberation of CO(2)). RESULTS: According to the different pressures exerted, the dimensions of the bubbles only vary by several microns, not measurable in practice. Second, the calibration of the echocardiograph reveals that the dimensions of the bubbles measured by ultrasound are greater by a factor of 1.75. Finally, the observed cavitation is a short phenomenon (several milliseconds) and happens under a great local pressure gradient. The degassing produces microbubbles lasting up to as long as > 1 second under much lower pressure. CONCLUSION: This in vitro study suggests that microbubbles observed during several hundred milliseconds after the opening of prosthetic cardiac valves are the result of degassing of CO(2) in blood rather than a cavitation phenomenon as suggested in the literature.
Abstract: We report the case of a repetitive and incessant activation of mode switch in a dual chamber pacemaker because of the inappropriate sensing by the atrial lead of far-fields signals from the ventricular evoked response. The incidence, consequences and prevention of the oversensing of far-field QRS complexes are discussed.
Abstract: The artificial activation of the heart modifies the mechanics of contraction and relaxation. While only little basic research has been addressed to this question, clinical observations showed that for hypertrophic as well as dilated cardiomyopathies appropriate pacing techniques can be useful.Pacing can influence the activation sequence. The spread out from a single site is slow, and so hypercontractility deminshed. With the use of multiple electrodes, two atrial and/or two ventricular, conduction delays in the atria or ventricles can be eliminated. Synchronisation of the cardiac activation has an anti-arrhythmic and positiv inotropic effect. This may lead to new indications for pacemakers or better to be named cardiac synchronisers.
Abstract: Infection of a cardiac pacemaker is a rare but serious complication. Percutaneous ablation of the pacemaker and pacing catheter is the only effective treatment. Techniques of extraction of pacing systems have been evaluated but the long term results require analysis. Eighteen patients with infection of cardiac pacemakers underwent extraction of one or more pacing catheters (14 atrial and 20 ventricular) in one same centre. The indication was infection of the pacemaker unit (12 cases) or septicaemia (6 cases) The causal organism was a staphylococcus (aureus: 7 cases, epidermidis: 10 cases, capitis: 1 case). Three techniques were used: 1) direct external manual traction, 2) internal traction with several devices, 3) endovascular counter-traction (Byrd-Cook system). The time from primary implantation of the pacing catheter to its extraction was 42 months and from last pacemaker manipulation to infection, 23 months. The average duration of the extraction procedure was 120 +/- 45 minutes; that of fluoroscopy was 10 +/- 6 minutes. The first technique was used 12 times, the second 8 times and the third 14 times, with complete extraction of the catheter in 88.2% of cases. The metallic tip of the distal electrode embolised in 2 cases and remained stuck in the right ventricle in 1 case. Only one pacing catheter was abandoned. After an average follow-up of 45 months, none of the patients had recurrent infection or any other complication. The authors conclude that extraction of infected pacing catheters is safe and effective. It is the treatment of choice of this complication.
Abstract: The authors analysed the long-term clinical and angiographic follow-up of patients after coronary stenting for the treatment of coronary stenosis of a native artery or vein graft. BACKGROUND: The need for revascularization at 6 months and the restenosis rate were decreased after coronary stenting, compared to the conventional percutaneous angioplasty. This benefit appears to persist in the longer term. METHOD: The incidence of major clinical and angiographic complications was evaluated in 129 patients with a minimum follow-up of 3 years. RESULTS: At 6 months, 20% of patients presented a major clinical complication and restenosis was documented in 20% of cases. In the long-term, a major cardiac event was observed in 49% of cases (death: 16%, infarction: 5%, coronary artery bypass graft: 12% and another angioplasty: 16%). Patients treated by stenting during coronary artery bypass graft had a significantly lower survival (60% versus 88%), and a higher incidence of major clinical complications (55% versus 18%), and a higher stent revascularization rate (41% versus 16%). CONCLUSION: The late stent revascularization rate was low. Overall survival was significantly higher in patients treated for a native vessel than in those treated for a coronary artery bypass graft. The complication rate and stent revascularization rate were also significantly lower.
