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A 31 year old woman with Marfan's syndrome had a dilatation of the aortic root (55-60 mm at the beginning of pregnancy). Pregnancy was continued with beta-blocker therapy and with regular echocardiographic follow-up. The aortic dilatation increased (62-65 mm) at the last control and, at the 34th week of pregnancy, the patient suffered a dissection of the ascending aorta. A caesarean section was performed with a Bentall procedure during the same operative session. The mother and baby girl are well two years later. The problems of pregnancy in patients with Marfan's syndrome are discussed.

The efficacy of a system of active diastolic synchronised coronary perfusion was studied during prolonged balloon angioplasty in 8 sheep. In the first part of the study (group 1) including 5 animals, the aim was to study the effects of high and constant flow (48 ml/min) for 90 minutes perfusion on haemolysis, the arterial wall and the perfused myocardium. The second part of the study (group 2), including 3 animals, assessed whether flow adapted to the extent of the vascular bed perfused (24 to 40 ml/min) could protect the myocardium for an interval of 60 minutes. In group 1, after 90 minutes of perfusion (48 ml/min), there was no haemolysis, or jet lesion of the arterial wall distal to the catheter tip. On the other hand, the creatinine phosphokinase levels increased at the 60th minute (188 vs 119 i.u./l for controls) and at the 90th minute (238 vs 119 i.u./l; p < 0.05). Moreover, the perfused myocardium was the site of histological lesions. These observations showed myocardial changes due to the "overflow phenomenon". In group 2, the flow rate was adapted to each animal, increasing progressively until disappearance of electrocardiographic signs of ischaemia (ST elevation) and maintained for 60 minutes. No signs of haemolysis, jet lesions or myocardial changes were observed, with absence of creatinine phosphokinase elevation and histological abnormalities. These preliminary results show that the system investigated allowed myocardial protection after arterial occlusion for an interval of 60 minutes.

A new circulatory system, "physiologic anteroperfusion system", has been developed and tested in 6 patients with significant proximal coronary artery stenosis. Prolonged and safe balloon inflation was possible without any ischemic signs. The system consists of an electronic cardiac synchroperfusor which, by activating a pulsatile unit, permits increased diastolic anteroperfusion of autologous blood under physiologic pressure through low-profile standard angioplasty catheters. This study reports the results obtained in 6 patients during proximal prolonged percutaneous transluminal coronary angioplasty. Four men and two women suffering from severe exertional angina pectoris, with normal resting left ventricular function, no collaterals and excellent apical two-dimensional four-chamber echocardiographic views were studied. After a 90 +/- 10 seconds of control occlusion under continuous monitoring of hemodynamics, electrocardiograms (3 to 4 leads), two-dimensional echo and chest pain grading, a second balloon inflation protected by the physiologic anteroperfusion system at a flow rate of 44 +/- 12 ml/min was performed for fifteen minutes. The ischemic signs present in the myocardium depending on the occluded artery were totally abolished during prolonged inflation protected by physiologic anteroperfusion system. All the patients were successfully dilated and were discharged from hospital the following morning without cardiac enzyme elevation or signs of central or peripheral hemolysis. Conclusion, in 6 patients with severe proximal coronary artery stenosis, safe prolonged proximal angioplasty without signs of ischemia was performed using a new simple physiologic anteroperfusion system, which allows active diastolic flow-pressure controlled autologous arterial blood perfusion, through standard low profile catheters.

The aim of this study was to evaluate the duration of the hemodynamic effects of a new slow release preparation of isosorbide dinitrate and to compare its action with placebo and a slow release nitroglycerin preparation whose hemodynamic efficacity has already been demonstrated. The study was undertaken in 30 patients admitted to the intensive care unit during the acute phase of myocardial infarction complicated by left ventricular failure less than 12 hours after the onset of the chest pain. The patient population was uniform: 24 males, 6 females, mean age 61 years. Fifteen patients had anterior infarcts and 15 posterior infarcts. The drugs were administered double blind in a randomised fashion to 3 groups of 10 patients, the initial clinical and hemodynamic characteristics of which were comparable: 10 patients received placebo (placebo group); 10 patients received slow release nitroglycerin in a 7,5 mg gelule (NTG group) and 10 patients received 40 mg slow release isosorbide dinitrate (ISDN group). The following parameters were compared: heart rate, right atrial pressure, pulmonary artery and capillary pressures, systemic arterial pressure, cardiac index and systemic and pulmonary arterial resistances. These parameters were measured before therapy, half an hour, one hour and every two hours up to the 8th hour after drug administration. All patients were in moderate left ventricular failure with an initial mean capillary pressure of 18 mmHg +/- 1,3 mmHg. In the placebo group, none of the parameters studied changed significantly during the study. Pulmonary artery pressure fell significantly by 11 p. cent in the NTG group and 7,5 p. cent in the ISDN group. Mean pulmonary capillary pressure fell progressively in both treatment groups; the change was significant compared to the placebo group from the first hour for the ISDN group, and from the second hour for the NTG group. The fall remained significant at the 8th hour for the ISDN group but not in the NTG group. Cardiac index, systemic blood pressure, systemic and pulmonary arterial resistances did not change significantly. The cardiac index remained stable in the 30 patients, but with a number of individual variations depending on initial mean pulmonary capillary pressure and the importance of its fall after nitrate administration. The authors conclude that the hemodynamic effects of slow release NTG and ISDN in the acute phase of myocardial infarction complicated by moderate left ventricular failure are comparable. Pulmonary capillary pressure was the hemodynamic parameter which underwent the greatest variation in the two treatment groups. Its fall was more prolonged in the ISDN than in the NTG group.

2D echocardiography is a great advance in the study of left ventricular aneurysms. The wide field of visualisation and the numerous planes of examination obtained from different transducer positions allow precise spatial orientation and reliable analysis of regional wall movement. An aneurysm appears as a clear and constant bulge of a segment of left ventricular wall in both diastole and systole. Antero apical aneurysms are the commonest variety. The sensitivity and specificity of 2D echo in the detection of ventricular aneurysms are high. Thrombosis within the aneurysmal bulge may also be detected (33-38%). Pseudo-left ventricular aneurysms are easily identified as a chamber communicating with the ventricle by means of a narrow neck; the width of this neck is the main echocardiographic feature differentiating pseudo and true ventricular aneurysms. 2D echocardiography gives valuable information on the state of the remaining contractile area, an important prognostic factor when surgical resection of the aneurysm is being considered.

The authors describe a case of an anomalous left coronary artery arising from the main pulmonary artery in an 11 year old child suffering from chest pain on effort and with a continuous murmur in the second left intercostal space. Two dimensional echocardiography (2D E) showed dilatations of the first segment of the right coronary artery and the anomalous origin of the left main coronary artery. A peripheral injection of microbubbles showed a left-to-right shunt between the left coronary artery and the pulmonary artery. Semi-quantitative evaluation of LV regional wall motion showed abnormal contraction of the anterolateral walls. Haemodynamic, angiographic data and the operative findings confirmed the diagnosis. The abnormal coronary ostium was closed and a bypass graft from the aorta to the left anterior descending artery was performed. Clinical and echocardiographic follow-up 7 months after surgery was completely normal.

Until recently, the diagnosis of aortic dissection rested on aortography. The purpose of this study was to evaluate the diagnostic value of echocardiography in that disease and its ability to inform on the extent of the dissection and on the presence of associated lesions. Twenty-six patients (mean age 64 +/- 10 years) admitted for suspected aortic dissection were explored by echocardiography and the results were compared with those of angiography and/or anatomical findings. Echocardiography provided the diagnosis in 14 of the 16 patients with aortic dissection and excluded it in the remaining 10 patients. The sensitivity and specificity of the method were 87.5 p. 100 and 100 p. 100 respectively. The type of dissection was correctly determined in 90 p. 100 of the patients whose aorta had been totally explored by echocardiography. Aortic regurgitation and pericardial effusion were detected in 81 p. 100 and 50 p. 100 respectively of patients with aortic dissection. These results confirm the diagnostic value of echocardiography in dissection of the aorta. The extent of the lesion can only be evaluated when the whole of the aorta is visualized. The echocardiographic diagnosis is easier when the ascending aorta is involved (type I), while in type III aortic dissection there is a risk of missing a retrograde lesion of the aorta and confusing this type with type I. In this study two kinds of intimal flap motion were observed: in the first one the motion was independent of that of the aorta, while the second one resembled a division of the aortic, wall the motion of which is parallel to that of the aorta.

The increasing number of physicians competent to carry out emergency echocardiography, and the availability of high performance equipment, facilitated the development of this technique in the Coronary Care Unit (CCU). This paper reports our experience of 610 2D echocardiographic recordings performed on 319 patients admitted to the CCU. The quality of the recording was excellent or satisfactory in 67% of cases and mediocre in 30% of cases. In 11 patients (3%) the quality of the recording was too poor to obtain reliable data. In this group of patients, the apical 4-chamber and subcostal views seemed better than the apical 2-chamber and parasternal views. An echocardiographic diagnosis was made in 94% of cases. It contributed to the diagnostic process in 70% of cases. Of the patients studied, 54% were admitted for a recent myocardial infarction. Echocardiography was particularly useful in atypical forms or when the diagnosis was difficult. It was also helpful in detecting complications of recent myocardial infarction, the frequency of which was determined. With respect to other cardiovascular emergencies, echocardiography was determined. With respect to other cardiovascular emergencies, echocardiography was very useful in the diagnosis of dissection of the aorta, pericarditis and for assessing left ventricular function and the causal mechanism in cases of decompensated cardiac failure. The non invasive nature of the investigation allows repeated examination of the patient at the bedside and makes it a particularly valuable technique to monitor the evolution of acute cardiac conditions requiring admission to the Coronary Care Unit.

The authors recall a case of moderate aortic incompetence caused by traumatic rupture of an aortic cusp occurring in a man of 36 years of age. Anatomical lesions of the aortic valve usually lead to severe incompetence for which surgical treatment is required. In this case, the lesion was well tolerated from the clinical and haemodynamic points of view, and surgery was not required; this tolerance has extended into the mid term. The authors emphasise the importance of echocardiography in the diagnosis of disturbance of an aortic valve, and also in following up the progress of the subsequent aortic incompetence.

The aim of this study was to assess the sensitivity of contrast echocardiography in the diagnosis of permanent (atrial septal defects, ASD) and transient (patent foramen ovale, PFO) interatrial communications under basal conditions, after Valsalva manoeuvres and coughing. Sixty-four patients suspected of having defects of the interatrial septum were studied. The results of echocardiography were compared with those of cardiac catheterisation, the classical method of reference. The sensitivity of contrast echocardiography was significantly improved in the diagnosis of PFO by the cough test (100%) compared with contrast echocardiography during spontaneous respiration (55%). Similarly, the cough test increased the sensitivity of contrast echocardiography in the diagnosis of ASD (96% compared to 83%). The specificity was good in both cases, about 90%. The cough test was a better method (98%) than Valsalva manoeuvres (59%) for the potentiation of interatrial right-to-left shunts. The results of echocardiography and catheterisation explain the mechanism of the right-to-left shunt during spontaneous respiration, Valsalva manoeuvres and coughing. The passage of the microbubbles from the right to the left atrium occurs during early systole when the atrioventricular valves are closed. The right-to-left shunt is potentiated by provocative manoeuvres. The demonstration of a right-to-left shunt by contrast echocardiography therefore indicates the presence of an interatrial communication; our results show that this non-invasive technique is a reliable method of diagnosing ASD and PFO.