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The article informs about archives of French departments published between 2017-2018 on several topics including interregional management of companies, economic competition and public finance.

Introduction La dénutrition protéino-énergétique est un facteur de risque de mortalité chez les patients (P) en hémodialyse (HD). Le but de l’étude est de déterminer si les apports alimentaires sont modifiés par la séance d’HD et d’en rechercher d’éventuels médiateurs. Patients et méthodes Un large choix d’aliments est proposé à des P dialysés, non diabétiques, non fumeurs, sans comorbidité évolutive, 2 jours consécutifs à 12 heures après l’HD et un jour sans HD. Les P choisissent la nature et la quantité d’aliments et leurs ingestions sont quantifiées. Des questionnaires avec échelle visuelle analogique permettent d’évaluer les critères de choix des aliments. Les concentrations plasmatiques d’acides aminés (AA) sont mesurées avant et après HD. Les tests statistiques utilisés sont le test de Student, t et t pairé. Résultats Dix-huit P (10 H, 8 F), d’âge moyen 69 ± 11 ans, sont inclus. Leur BMI est de 26 ± 5,8, leur albuminémie de 37,7 ± 3,9 g/L, leur préalbuminémie de 322 ± 82 mg/mL. Après l’HD, les P mangent significativement plus de protéines (test de t pairé) : 68,9 ± 19,8 g vs 58,6 ± 21 g ( p = 0,004), soit une différence de 18 %, alors que les ingestions de glucides (40 ± 4 g vs 40 ± 5 g) et de lipides (75 ± 20 g vs 70 ± 22 g) ne sont pas différentes. L’apport calorique total n’est pas différent après l’HD (1114 ± 254 kcal vs 1027 ± 297 kcal, p = 0,08). Les P mangent plus de protéines du fait de leur faim (8,53 ± 2,44 vs 7,9 ± 2,6, p = 0,008). L’HD induit des réductions significatives d’AA plasmatiques. Discussion la séance d’HD est suivie d’une sensation de « faim spécifique » et d’ingestion significativement accrue de protéines sans modification des apports caloriques ni des autres nutriments. Conclusion Les prescriptions diététiques doivent recommander un apport protéique plus riche après HD pour lutter contre la dénutrition protéino-énergétique. Comme chez l’animal, les diminutions d’AA plasmatiques pourraient être associées à ce comportement alimentaire. [ABSTRACT FROM AUTHOR]

Introduction La maladie rénale chronique (MRC) est un enjeu majeur de santé publique. Les cohortes sont des outils épidémiologiques d’intérêt pour rechercher les liens entre les facteurs biologiques, comportementaux et environnementaux et les effets sanitaires. Un tel outil apparaît alors essentiel pour connaître les trajectoires d’évolution des patients avant mise en place d’un traitement de suppléance et l’exploration plus large des déterminants sous-jacents à ces différents profils d’évolution. Patients et méthodes Nous présentons ici une étude de cohorte prospective ouverte sans horizon temporel déterminé, spécialisée dans la MRC pré-suppléance nommée Non-dialysis – chronic renal insufficiency study (ND-CRIS). Ont été inclus les patients prévalents et incidents de plus de 18 ans avec un débit de filtration glomérulaire estimé < 60 mL/min/1,73 m 2 (MDRD), informés et n’ayant pas exprimé un refus, pris en charge par les néphrologues de différents centres hospitaliers de la région Bourgogne Franche Comté. Les variables ont été recueillies de manière passive par des assistants de recherche clinique à l’aide d’un formulaire électronique dédié. La cohorte a reçu les accords du CCTIRS et de la Cnil. Résultats Cette étude a débuté par une phase pilote d’une durée de 3 ans (2012–2015) menée dans 3 centres de la région Bourgogne Franche Comté (Besançon, Mâcon, Belfort-Montbéliard) ayant permis l’inclusion de 1849 patients avec un taux de refus de participation bas (51 non participants). Depuis 2015, 6 centres supplémentaires de la même région ont été ouverts avec à la fin décembre 2016, 3452 patients inclus. Le suivi moyen est de 17,4 mois pour les 2443 patients ayant au moins une consultation de suivi. Discussion La cohorte ND-CRIS comble un manque d’outil épidémiologique en France dans la MRC. En effet, les cohortes actuelles sont à inclusion fermée présentant comme limites la perte de représentativité dans le temps et l’impossibilité de surveiller des tendances temporelles sur le long terme. Conclusion Le caractère ouvert et incident et le nombre de patients inclus devraient permettre de répondre à des questions auxquelles des cohortes prévalentes de plus petite taille ne peuvent répondre. Cette cohorte peut également servir de plateforme de recherche et d’outil de monitoring de santé publique. [ABSTRACT FROM AUTHOR]

Introduction Dans l’insuffisance rénale, la connaissance de la typologie des patients et de leur parcours de soins est un enjeu pour les professionnels de santé et pour les tutelles afin d’adapter les moyens alloués à leur prise en charge. L’étude Non-dialysis – chronic renal insufficiency study (ND-CRIS) est une cohorte prospective ouverte sans horizon temporel, réalisée en région Bourgogne–Franche Comté étudiant des patients atteints de MRC de stade 3 et plus mais non dialysés. Patients et méthodes Les patients adultes sont recrutés depuis 2012, à l’occasion d’une consultation auprès d’un néphrologue. Leurs données cliniques et biologiques sont recueillies par un attaché de recherche clinique à partir du dossier médical de la structure dans laquelle ils sont suivis par leur néphrologue habituel. Fin 2016, près de 3500 patients sont inclus permettant d’établir une première photographie de la MRC dans cette région. Résultats Au total, 3452 patients ont été inclus : 2061 hommes, 1391 femmes soit un ratio H/F de 1,48. Âge moyen : 72 ans (19–99) identique pour les 2 sexes. Néphropathies vasculaires 32,4 % mixte (diabète-hypertension) 16 % diabète seul 8,6 % glomérulopathies 9 %, néphropathies tubulo-interstitielles 6,4 % pkrd 4,1 % autres 5,6 % inconnu ou non disponible 17,7 %. Stades de la MRC : 3A : 22 %, 3B : 39,3 %, 4 : 31,5 %, 5 : 6,9 %. Hypertension (HTA) : traitée chez 3109 patients, considérée équilibrée pour 33,7 % d’entre eux seulement. Discussion Le patient type suivi pour une MRC de stade 3 ou plus en Bourgogne–Franche Comté appartient majoritairement au 3 e ou au 4 e âge. Il s’agit plutôt d’un homme sauf dans la tranche des plus de 90 ans du fait de la survie plus longue du sexe féminin identique à la population générale. Il est souvent traité pour une HTA insuffisamment équilibrée dans 2/3 des cas malgré le recours à une association d’anti-hypertenseurs chez 75 % des patients. Conclusion La cohorte ND-CRIS, prospective et ouverte est un outil performant qui, au-delà de cette photographie à l’inclusion des patients atteints de MRC permettra dans les années qui viennent d’évaluer leur évolution clinique et biologique tout au cours de leur parcours de soin. Elle mesurera également les interventions du néphrologue sur leur devenir. [ABSTRACT FROM AUTHOR]

The management of acute coronary syndrome (ACS) with ST elevation in daily practice does not always comply with the official guidelines. In effect, many patients do not benefit from coronary recanalisation despite being eligible. They could be described as the 'reperfusion forgotten ones'. The Limousin ESTIM study allowed us to evaluate their numbers and characteristics between 2001 and 2003. Between 1 June 2001 and 31 December 2003, 958 patients with ST+ ACS were managed within 24 hours. Among this cohort, 47% of patients did not benefit from reperfusion treatment with fibrinolysis or angioplasty. In spite of early management, the rate of non-reperfusion was significant: 30% before the third hour, and 50% between 3 and 6 hours. With univariate and multivariate analysis, the predictive features for non-reperfusion were age, length of time between onset of pain and presentation, type of admission route, absence of a call to the emergency ambulance service, and the characteristics of the ECG tracing. These data have prompted education and training, adapted for specific regions. Despite some significant improvements, the rate of non-perfusion in 2004 still remains 35% in the first 24 hours, comparable with figures in the recent literature. Being aware of this problem, taking specific action and continued evaluation with surveys like this remain important.

Ventricular tachycardia by branch to branch reentry is a rare arrhythmia. It occurs in cardiomyopathies associated with conduction defects. During tachycardia a His potential precedes each QRS complex which usually has a left bundle branch block appearance. The authors report two familial cases of ventricular branch to branch tachycardia (son and mother) without cardiomyopathy. The diagnosis of Steinert's disease was made post-mortem in these two patients. In cases of branch to branch ventricular tachycardia, the diagnosis of myotonic dystrophy should be excluded. Conversely, endocavitary electrophysiological investigation with ventricular stimulation should be proposed for symptomatic patients (dizzy spells, syncope) to diagnose branch to branch ventricular tachycardia, even in cases with conduction defects which could also explain the symptoms.

Background: Lactobacillus is a commensal germ found in the buccal cavity, the digestive tract and the vagina. Usually non-pathogenic except in case of dental caries, it can occasionally be the causal agent in severe endocarditis., Case Report: A 70-year-old woman developed endocarditis on an aortic valve bioprosthesis. Lactobacillus acidophilus was isolated from blood cultures of the valve after surgery., Comments: Forty-four cases of Lactobacillus endocarditis have been reported in the literature to date. Mortality is high (26%). The main difficulty in treatment is germ tolerance to penicillin and aminosides found in all cases. Cure requires high dose parenteral antibiotics and surgery in many cases (26%).

This paper reviews the current state of knowledge about smoking after myocardial infarction in smokers. After presenting results emphasizing the value of post-infarction smoking cessation, all of the predisposing factors to smoking cessation are analysed. The objective of this review of the literature is to recognize these factors in order to more precisely define the various medical, psychological and social aspects of an assistance programme adapted to post-infarction smoking cessation.

Adult's progeria or Werner's syndrome is a rare condition of autosomal-recessive inheritance, characterized by an apparent acceleration of many of the processes associated with aging. We describe the cardiovascular findings in a 44 year-old man with this disorder. Slightly elevation of urinary hyaluronic acid level contributes to the diagnosis.

The authors studied flow in the internal mammary artery by Doppler ultrasonography after bypass surgery of the left anterior descending artery to determine the correlation between the flow pattern and the quality of the distal run off. A pulsed Doppler was used to record flow from the right and left internal mammary arteries in the first, second and third intercostal spaces and the supraclavicular fossa. Only the best quality recordings with the highest amplitudes were retained for analysis. Forty-nine patients (average age 61 +/- 10 years), 43 men and 6 women, were included and were examined between the 10th and 15th postoperative days. All had stenosis of the left anterior descending on coronary angiography: three subgroups were identified ad the time of evaluation: (I) revascularisation of an infarcted zone with important angiographic and echographic sequellae. (II) revascularised zones with slight wall motion abnormalities. (IIIa) revascularisation of myocardium with no abnormality (including a subgroup of 5 patients (IIIb) characterised by a postoperative low output state and echocardiographic changes not present before surgery). Significant changes were observed in the flow patterns of the different groups. (I) an exclusively systolic flow (diastolic velocity time integral = 2.85 cm), (II) systolodiastolic flow (diastolic velocity time interval = 9 cm) similar to that in group IIIb, and IIIa predominantly diastolic flow (diastolic velocity time integral = 15.2 cm). The amplitude of diastolic flow in the mammary artery graft was therefore related to previous ischaemia of the revascularised myocardium; detection of stenosis by Doppler ultrasonography should therefore take into account the previous history of the patient.

The authors report the case of a 42 year old man who smoked and who presented with recurrent spontaneous anginal chest pain followed by syncope due to sinus arrest. The mechanism underlying these symptoms was spasm of the left circumflex artery at the site of severe stenosis of its middle segment just before the origin of the sinus node artery. Treatment with a calcium antagonist with transluminal coronary angioplasty of the narrowed segment of the circumflex artery resulted in complete regression of all symptoms with a follow-up of 15 months. Seven other reports of the same type were found in the literature concerning 6 men and 1 woman, with an average age of 49 years, presenting with the same symptoms and sinus arrest associated with the minimal coronary artery disease. The proof of coronary spasm was documented in 6 of the 7 cases by a positive ergometrine stress test or by the observation of spontaneous spasm during coronary angiography or rapid atrial pacing. The outcome was good with calcium antagonist therapy in 5 cases, and with slow release nitrate derivatives in 1 case. One patient, treated by betablockers, died. It is useful to investigate some sino-atrial blocks to diagnose the underlying ischaemic mechanism as the patients may be treated simply with calcium antagonists rather than undergo implantation of a pacemaker.

Five hundred patients with a mean age of 59 years were followed up for an average of 32 months after coronary angioplasty. All patients were included in a prospective study comprising coronary angiography at 6 months for 379 patients (91% primary successes). The long-term outcome was evaluated by a questionnaire or telephone interview in all cases. The global primary success rate was 84.4% in this series. The primary failures include 1.8 fatalities, 0.6% myocardial infarction, 2% emergency coronary bypass surgery and 11.2% without immediate clinical consequences. At 6 months, there were 48% of restenoses (182/379 patients) and 28% underwent immediate repeat angioplasty (141/500 patients) with a primary success rate of 91%. After the repeat angioplasty, the restenosis rate was 43% but this varied according to the time from the first restenosis: 60% when the interval was short (under 2 months) compared with 21% when the interval was 6 months (p < 0.01). The actuarial survival rates at 4 years were 95% after successful angioplasty 96% after uncomplicated failures or medically treated restenosis and 98% after bypass surgery. The predictive factors for secondary death were age of over 70 years, previous non-thrombolized myocardial infarction and complications of angioplasty. The long-term outcome was good despite the 48% 6 months restenosis rate requiring revascularisation procedure in 73% of cases.

Significant left main coronary artery disease is a separate disease entity in coronary artery disease. The prognosis is classically poor and the treatment of choice is surgical. A retrospective study of patients with left main coronary disease, diagnosed and treated at the CHRU Dupuytren, Limoges, between 1/01/80 and 15/06/91 was undertaken to determine the aetiological, clinical and therapeutic factors which influence mortality related to this condition. During this period, 8198 coronary angiographies were performed in the cardiology department. The diagnosis of significant left main coronary disease (> or = 50% stenosis) was made in 250 cases (3% of all investigations). Of these 250 cases, 227 were treated medically or surgically by our group during the study period. Twenty patients were treated in another centre and 3 underwent surgery after the 15/06/91. Seven patients died in the period immediately after coronary angiography. Of the 220 survivors of coronary angiography, 185 (85%) were referred for surgery (direct or sequential venous and/or arterial bypass or coronary endarteriectomy). Four patients died within 30 days of surgery. Thirty five patients were treated medically. The therapeutic decision was based on the absence of surgical contra-indications. The retrospective, non-randomized nature of this study with allocation of patients to surgical or medical treatment without control invalidated statistical analysis. At the date of the last follow-up appointment, arbitrarily chosen as the 1/01/93, 163 operated patients (88.1%) of which 130 (79.7%) were asymptomatic and 13 medically treated patients (37%) were alive. The prognostic factors after surgery in this study were: stage IV dyspnoea at the time of diagnosis, severe abnormalities on catheter study (end diastolic pressure over 18 mmHg after angiography), left ventricular wall abnormalities (functional score > 10) and incomplete revascularization. The risk of coronary angiography in this condition were confirmed in this study.

77 pure iliac aneurysms where detected in a group of 48 patients along a period of 21 years, and represented 12.3% of all patients having aortic, iliac, or aorto-iliac aneurysms. The study group comprised 42 men and 6 women, 48-86 years old (mean 67.8 years). The aneurysm was located on the right side in 51.9%, on left side in 48.1%. The affection of the common iliac arteries (70.1%) was more frequent than it was on the internal iliac arteries (18.2%), or in the external iliac arteries (11.7%). The diameter was from 2 to 10 cms. 44 patients out of 48 (91.6%) where symptomatic, and 15 presented a rupture syndrome (31.3%). 10 patients (20.8%) had a pulsating mass. The etiology was unknown in 8 cases (16.7%); 2 patients had a mycotic aneurysm (4.2%). The remaining 38 patients (79.1%) had an aneurysm of atheromatous origin. 5 arteritic patients (10.4%) did not have any cure for their aneurysm, because it was considered threatening for 4 of them. The fifth patient was not treated because the artery was so calcified that it could not be clamped. A lumbar sympathectomy on the same side of the lesion was realised, in addition to the peripheral surgical act for arteritis. One patient had an endoaneurysmorrhaphy, another had an exclusion by ligature section of the aneurysm. For the remaining 41 patients (83.1%) the aneurysms where flattened, and vascular continuity was re-established by a prosthesis. 7 patients (12%) decreased post-operatively.(ABSTRACT TRUNCATED AT 250 WORDS)

We report about one case of acute dissection of the infrarenal abdominal aorta associated with a horseshoe kidney. A few points in the history of this 47-year-old patient deserve being underscored: the absence of an "etiological" factor of aortic dissection, the presence of five renal arteries, illustrating the complex vascularity of a horseshoe kidney, the specific surgical problems arising from both a lesion of the aortic junction and a horseshoe kidney. On the basis of the literature, we underline the incidence of dissection of the infrarenal aorta (1 to 3%), that of horseshoe kidney (0.15%) and that of pathology of the aortic junction in patients with a horseshoe kidney, which seems to be accidental.

The authors report about one case of bacterial endocarditis complicated by fungal aneurysms in a superior mesenteric and a popliteal site. While the diagnosis was easy for the popliteal aneurysm, it was not so for the mesenteric aneurysm. Arteriography must have wide indications. The treatment of such aneurysms must always be medical, but surgical as well. The surgical tactics must be carefully discussed, and the restoration of vascular continuity with autologous venous material through an extra-anatomic course should be preferred.

We report about a 66-years-old obese and diabetic female patient, treated with anti-inflammatories for osteoarthritis of the hip and operated for varices of the lower limbs by a bilateral stripping of the internal saphenous veins, who presented with a mortal necrotizing fasciitis during the postoperative period. Necrotizing fasciitis is a severe, infrequent disease jeopardizing the vital prognosis, in which an appropriate and early treatment (medical, using antibiotics, and surgical by extensive debridement) can prevent a fatal outcome. The most often involved germs are streptococci (45%). The association of anaerobic and aerobic germs sometimes causes mixed cellulitis. The vital prognosis is always threatened by postoperative fasciitis. The mortality rate ranges from 50 to 75%, the main causes of death being a septic shock or pulmonary embolism. The functional prognosis of the surviving patients depends on the extent and quality of surgery.

The authors report the case of a 44 year old man with a giant leiomyoma of the lower third of the esophagus. The patient presented with chest pain and the tumour was detected by echocardiography. The diagnosis was confirmed by computerised tomography and histological examination of the surgical specimen weighing 501.5 g. The surgeon performed a large esophago-gastric resection and reestablished the continuity of the digestive track by interposing a section of colon. A good result was obtained with a follow-up of 4 years. The authors underline the potential value of a simple barium swallow during cardiological assessment.

The scope of acquired valvular heart diseases has evolved in France during the past 15 years towards a regression of the rheumatoid etiology with emphasis on degenerative and dystrophic diseases. At the same time, the evaluation of valvular diseases has benefited from the considerable advances in isotopic and mostly ultrasonic non-invasive techniques, not to mention more sophisticated techniques such as nuclear magnetic resonance imaging still infrequently used. The different technical variation of sonocardiography, from the TM and bidimensional sonography to transesophageal sonography and continuous and color coded pulsed echo-Doppler, provide reliable answers to the various questions raised before considering a surgical procedure. The remaining role of invasive techniques, such as cardiac catheterization and angiocardiography, considered as the "gold standard" until recently, and reviewed for each valvular disease whether isolated or combined, is becoming more and more restricted. Only coronary angiography remaining the undisputed and absolutely necessary test in case of angina, complications of myocardial infarction, risk or age factors.

An automatic and quantitative analysis method for tomographic scintigraphy was applied to 104 patients with myocardial infarction (anterior 37, inferior 67, lateral 20, involving 2 territories in some cases). All patients underwent exercise and redistribution scintigraphy and coronary arteriography which served as reference. Two types of tomographic sections were used: 2 short axis sections exploring the left ventricle at different levels, and 1 apical section at a right angle with the first ones. A circumferential analysis program studied the isotopic activity of each section and drew an activity profile curve which was compared with those obtained in normal subjects. Exercise curves proved superior to redistribution and wash-out curves and were therefore used exclusively. Two sectoring methods for territories with infarcts were defined: conventional sectoring, which gives a 90 degrees angle to the anterior region and a 180 degrees angle to the inferior lateral region, and real sectoring established from the scintigraphic abnormalities observed in patients whose infarction was not accompanied by significant lesions in other territories. Real sectoring divides the territory into two regions (anterior and infero-lateral) and determines the extension territory and the territories specific to each necrotic region. The sensitivity and specificity of these two methods for the diagnosis of necrosis and the detection of a significant abnormality (greater than 70% stenosis, or necrosis) in a territory other than the one with infarct were compared. In the diagnosis of infarction: conventional sectoring sensitivity 92%, specificity 46% for anterior infarcts, 94% and 25% for inferior and lateral infarcts; real sectoring 94% and 63% respectively for anterior infarcts, 92% and 68% for inferior infarcts.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular ejection impediment is one of the complications of mitral valve replacement, especially in case of isolated mitral stenosis with small left ventricle. The use of a "low profile" valve does not prevent this complication. The diagnosis is based on catheterization but the advent of the ultrasound-Doppler may make it easier.

Two cases of septicaemia on endocavitary cardiac pacemaker probes lead the authors to discuss the aetiological and therapeutic aspects of this type of infection. In both cases, the pacemaker had been in situ for a long time and had been replaced on several occasions, there was infection in the site of implantation and an attempt at removal of all of the pacemaker material failed, leaving a probe incarcerated in the right ventricle by one of its extremities with the other extremity floating free. The endocarditis associated with this septicaemia can, theoretically, be due to two mechanisms: metastatic implantation of infection form a distant site which must be detected or infection developing in contact with the pacemaker and propagated along the probe. The treatment of this type of septicaemia consists of appropriate antibiotics, which are only rarely sufficient to sterilize the infection. In most cases, all of the pacemaker material must be removed, which is easily achieved in the majority of cases. After cleansing of the site, the pacemaker has been successfully replaced. Sometimes, the probe is buried in the myocardium: surgical removal by cardiotomy, with or without extracorporeal circulation, seems to be preferable to the techniques of continuous traction which carry certain risks (tricuspid and myocardial lesions). Persistent floating probes must be removed surgically.

The authors report 11 cases of spikes occurring under bepridil treatment. It concerns an elderly population, predominantly female, receiving most of the time 300 mg of bepridil. The frequency of associated hypokalemic or arrhythmic medications is emphasized. The comparison of these results to those from other series in the literature, enables to propose precautions for the use of this molecule.

The authors report a case of chronic constrictive pericarditis in a 54 year old patient who had undergone aortic valve replacement 6 years previously. The valve was replaced with a Starr-Edwards prosthesis because of aortic regurgitation due to infective endocarditis. The outcome after pericardectomy was favourable with a 3 year follow-up. This complication of cardiac surgery, of which there are now 45 reported cases, should not be overlooked because it can be cured surgically. The diagnosis is based on phonomechanographic, echocardiographic and, above all, haemodynamic investigations to distinguish the condition from irreversible myocardial dysfunction.

Fourteen methods of analysing left ventricular wall motion on 30 degrees right anterior oblique left ventricular cineangiography were compared in 70 cases using a HP 9845 B computer. The methods included the superposition of the centres of gravity, perpendicular to the long axis, Leighton's Rickard 's, Ingels ' and others to determine the influence of the use of different anatomical points of reference on the results. A score was given for each programme in comparison with three groups of normal angiography, anterior infarction and inferior infarction limited to a single zone with no lesion on the opposite coronary artery. The score was the ratio of radial shortening of normal wall motion to that of the infarcted wall. The fourteen methods were divided into 4 groups according to the type of infarct studied (anterior or inferior) and according to the use of either percentage radial shortening or the ratio of the surfaces described by these radii and the systolic and diastolic contours. The results underlined the importance of the anatomical references : aortic orifice and apex for centering systolic and diastolic contours. The methods which did not take these factors into account or which did not correct for them in diastole and systole gave poor results. The centre of gravity of the systolic contour was also an unreliable reference point. The three methods which gave the best results, independent of the site of infarction or the method of calculation (ratio of the radii or surfaces) were all based on the long axis from the aortic orifice to the apex.(ABSTRACT TRUNCATED AT 250 WORDS)

The degree of severity of coronary artery lesions and the quality of the distal vessels which justify revascularisation by by-pass grafting were studied in 1,000 consecutive cases of coronary angiography. The results are presented in terms of the clinical indication for coronary angiography and in terms of the patients' age and sex. 47% of patients were investigated because of unstable angina and 53% of them had surgical lesions. 16% of the angiographies were performed three weeks after myocardial necrosis. 45% of these patients had a surgical lesion in a coronary territory other than that of the necrotic area. In 20% of cases, the coronary angiography was performed as part of the pre-operative work-up for valvular heart disease. 17% of these operations combined a by-pass graft with the valve replacement. Independent of the indication for coronary angiography, 20% of cases had major coronary artery stenoses which reduced the lumen by more than 70% and which were inoperable.

The authors studied the clinical course of 100 patients with two or three vessel coronary artery disease who were unsuitable for surgery because of the poor quality of the distal vascular bed or excessively depressed left ventricular function. The 6 year actuarial survival was 58 per cent; 43 of the 100 patients did not present any serious cardiac events causing death or requiring further admission to hospital, over this follow-up period. The severity of the clinical course in women and the presence of heart failure prior to coronary angiography were considered to be among the most important clinical prognostic factors. On the basis of the haemodynamic survey, the probability of survival or the risk of a further coronary accident appears to depend more on the extent of the left ventricular kinetic abnormalities than on the ejection fraction or the severity of the coronary lesions.

100 patients over the age of 70 years underwent coronary angiography. The indications for this examination at this age were different from those in younger patients. After the age of 70 years, 58 per cent of coronary angiographies are performed as part of the haemodynamic survey of valvular disease. The risk of the examination appears to be higher, as two deaths occurred in this small series, while the mortality is estimated to be 2 per thousand in younger patients. Coronary angiography is very useful at this age in patients with valvular disease to determine the need for an associated coronary graft and also to determine contraindications for operation because of the severity of the lesions. A surgical indication was confirmed in 50 patients, but surgery was only performed in 36 of them. The follow-up of these patients demonstrates that patients operated for valvular disease had a longer survival that those considered to be inoperable or who refused operation. On the other hand, there was no difference in survival between grafted and non-operated patients over the age of 70 years.

Surgery may prolong survival in some patients in advanced cardiac failure due to valvular heart disease refractory to digitalo-diuretic and vasodilator therapy. The operative risk is high and myocardial dysfunction after surgery is also a problem. However, in some cases, surprising improvement is observed. An analysis of the principal publications in the literature on the natural history of valvular heart disease and the results of surgery in the last ten years show that: In chronic aortic valve disease complicated by congestive heart failure, the natural prognosis does not exceed 2 to 3 years in either aortic stenosis or regurgitation. On the other hand, prosthetic valve replacement is associated with a 57% 4 years survival in aortic regurgitation, and a 70% 5 years survival in aortic stenosis, but with an operative mortality of 20 to 27%. Surgery is even more valuable in acute aortic regurgitation due to endocarditis, leading to a 60% 2 years survival compared to only 6% with medical therapy alone. In chronic mitral valve disease with advanced cardiac failure, the natural prognosis does not exceed 4.5 years in mitral regurgitation, 8 years in mitral stenosis and an intermediate period in mixed mitral valve disease. On the other hand, prosthetic valve replacement with an operative risk of 21 to 26% is associated with a life expectancy of 56 to 60% at 5 years, and 46% at 10 years, operative mortality included. The surgical results depend on good myocardial protection and intensive pre-, per- and post-operative care using positive inotropic agents, vasodilators and, when necessary, intra aortic balloon pumping.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report the case of a 72 year old patient with ECG changes of anterior myocardial infarction complicated by left ventricular failure and shock which has a favourable outcome with regression of the pathological Q waves on the 7th day. Radionuclide investigation and coronary angiography showed no myocardial sequellae and the coronary arteries appeared normal. This case, an example of stunned myocardium, confirms that severe myocardial ischaemia, even of short duration, may induce reversible but prolonged metabolic disturbances. The practical implications of this concept are discussed.

The diagnosis of dissection of the aorta is based on clinical examination, echocardiography and angiography of the aortic arch. Continuous Döppler ultrasonography may also be useful as a very suggestive abnormality of the wave form can be recorded from the dissected vessels, comprising a deep early mid systolic notch which gives the wave a double hump appearance. This phenomenon, observed in two type I dissections, was recorded from the right subclavian and vertebral arteries in the first case in which the initial components of the systolic wave of the right carotid artery were also amputated. In the second case, the phenomenon was recorded from all vessels arising from the aortic arch. The underlying mechanism could be herniation of the false into the true arterial lumen leading to temporary obstruction of systolic ejection. Another possibility is the successive recording of blood flow first in the true and then in the false lumen. Midsystolic Döppler abnormalities have also been described in aortic regurgitation, hypertrophic obstructive cardiomyopathy, atheromatous plaques causing a valve effect; however, the timing, morphology and extension of these abnormalities are quite different. In practice, the finding of this abnormality is an additional argument in favour of the diagnosis of dissection of the aorta. Continuous Döppler ultrasonography is also a good method of assessing the peripheral consequences of the dissection.

103 patients with atrial fibrillation lasting more than 15 days were treated by cardioversion, with a return to normal sinus rhythm in 92 per cent of cases. If the atrial fibrillation recurred during the first six months, a further electric shock was given and the treated was changed or better adapted to the patient. The sinus rhythm was maintained in 85.7 per cent of patients at one year, 84.4 per cent at 2 years, 80.1 per cent at 3 years and 76.1 per cent at 4 years. The factors which predict a good result are: sex, the presence of mitral valve disease, especially when it has been operated, good tolerance of the arrhythmia and good haemodynamic status prior to the shock. The treatment used were quinidine arabogalactane sulfate (QAGS) and amiodarone. QAGS was better tolerated, while amiodarone proved to be more effective.

Three cases of interstitial pneumopathy secondary to amiodarone are reported, in addition to almost 200 cases previously published in the literature. The main clinical, radiological, biological and evolutive characteristics are reminded in emphasizing the advantages of bronchioalveolar irrigation. Some factors seem to be predisposing, without any definite proof however. They are: high daily dosage, long term treatment, high cumulative dose, concomitant ingestion of another anti-arrhythmic medication, especially in elderly patients, and in patients who, before any treatment, presented a decreased total pulmonary capacity and a CO transfer capacity lower than 80 p. cent of the theoretical values. Discontinuation of amiodarone and administration of steroids usually produce a rapid regression of the clinical and radiological symptoms.

Two fairly similar cases of internal mammary arterio-venous fistula were observed in two patients involved in serious road accidents, following which a catheter was inserted into the subclavian vein for the purposes of resuscitation. The clinical diagnosis was made in both cases on routine examination, which revealed a continuous right subclavian bruit with extensive radiation three years after the accident. There were no functional implications. Further investigations revealed a fistula located between the internal mammary artery and the right brachiocephalic venous trunk and demonstrated the haemodynamic consequences: normal intra-cardiac pressures, but a pulmonary blood flow which was twice that of the systemic blood flow. Both cases were treated by means of surgical cure via thoracotomy, which confirmed the nature of the arterio-venous fistula and which defined the relations with the phrenic nerve, which is the most exposed element. The results of this operation were excellent in both cases.