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1. Pulsatile changes in the diameter of the common carotid artery were studied transcutaneously using an echo-tracking technique in 15 normal subjects: eight subjects before and during application of graded lower-body negative pressure from -5 to -15 mmHg, and seven subjects before and during weight-bearing head-up tilt at 30 and 60 degrees. 2. In concomitant studies of changes in forearm vascular resistance, it was seen that mild lower-body negative pressure produced deactivation of cardiopulmonary receptors without changes in systemic blood pressure or heart rate. 3. After lower-body negative pressure, a significant decrease in carotid arterial diastolic diameter [from 0.662 +/- 0.028 to 0.624 +/- 0.033 cm (lower-body negative pressure -10 mmHg) and 0.640 +/- 0.030 cm lower-body negative pressure -15 mmHg), P < 0.001 and < 0.05] was observed. 4. After head-up tilt, carotid arterial diameter was also significantly decreased at 30 and 60 degrees, whereas a significant increase in heart rate occurred only at 60 degrees and mean blood pressure did not change. 5. The study provides evidence that the geometry of the arterial wall is substantially modified by non-invasive manoeuvres such as head-up tilting and lower-body negative pressure. The latter is assumed to selectively deactivate human cardiopulmonary receptors, but the present data suggest that local changes may also influence carotid baroreceptors.

The risk of sudden arrhythmic death after myocardial infarction is high, especially during the first months. The evaluation of this risk should be performed before hospital discharge in the same way as residual ischaemia and left ventricular function, which are independent risk factors for arrhythmia, are assessed. Holter monitoring provides information not only about ventricular hyperexcitability (especially the detection of unsustained ventricular tachycardia) but also about the activity of the autonomic nervous system by analysis of variations of the sinus rhythm, the decrease of which carries a poor prognosis. The search for an arrhythmogenic substrate requires signal averaged electrocardiography, but although the absence of late potentials carries a good prognosis, the positive predictive value of this investigation is very low. The association of non-invasive indices of poor prognosis greatly increases the probability of a major arrhythmic event; this may require consideration of programmed ventricular pacing, another method of substrate and risk assessment, which has the added advantage of sometimes indicating the most appropriate therapy.

The aim of this study was to assess the value of routine transoesophageal echocardiography in the early postoperative period after mitral valve replacement. The authors report their experience in 50 consecutive operated patients (43 mechanical and 7 bioprostheses) investigated routinely by this method in the postoperative period in the surgical unit. Abnormal findings were observed in 36% of cases (18 patients): trans-prosthetic leaks (8 cases) and thrombosis (10 cases) in 2 bioprostheses and 8 mechanical prostheses; in 3 cases this led to haemodynamic dysfunction but in 7 cases the thrombus had no influence on the trans-prosthetic pressure gradient. No predisposing factor could be identified (spontaneous contrast, left atrial volume, left ventricular function, poor anticoagulation, blood clotting abnormalities). No abnormality of the mobile components of the prosthesis was observed at radioscopy. The outcome with heparin therapy was favourable with disappearance of the thrombi in 6 cases; the thrombi did not regress in 4 patients on heparin: 2 patients underwent thrombolytic therapy with a complete cure in 1 case and a severe embolic complication in the other; in 2 cases, the thrombus was so big that the patients were reoperated. Systematic early postoperative transoesophageal echocardiography before discharge from the surgical unit would seem to be necessary after early mitral valve replacement: it allows diagnosis of asymptomatic thrombosis which has an important emboligenic potential. The management of these thromboses remains controversial, but the poor natural outcome in cases of large thromboses should lead to referral for early reoperation.

Catheter ablation of the atrioventricular junction may be proposed for the treatment of certain atrial arrhythmias resistant to antiarrhythmic therapy. One of the methods currently being evaluated uses radio-frequency energy which has certain advantages compared with direct current ablation because of the progressive and limited lesions it produces. This technique was used in 24 patients with atrial arrhythmias resistant to antiarrhythmic therapy. The radio-frequency energy was delivered without general anaesthesia with HAT 100 and 200 (OSYPKA) generators in the unipolar mode (average 17.4 watts) for an average period of 22.3 +/- 8 seconds. The catheter (8F USCI suction catheter in the first 18 patients and a 7F Polaris Mansfield, deflectable catheter with a large distal electrode in the remainder) was positioned at the nodo-hisian junction at a point where the two distal electrodes recorded a large atrial deflection and the smallest possible hisian potential. The conduction defects induced during the acute phase generally remain stable in cases of complete atrioventricular block and tend to regress in cases of incomplete atrioventricular block despite initial control of atrioventricular conduction. During follow-up (21 +/- 16 months), 14 patients (58%) remained in complete atrioventricular block, 4 patients (17%) had controlled atrioventricular conduction with an acceptable ventricular rate with associated previously ineffective antiarrhythmic therapy. Radio-frequency ablation was a failure in 6 patients (25%). There were no haemodynamic, rhythmic or ischaemic complications during the acute phase or during follow-up. These results suggest radio-frequency energy is a seductive alternative to direct current ablation for percutaneous modification of atrioventricular conduction in patients with refractory atrial arrhythmias. However, simple modulation of atrioventricular conduction gives aleatory results due to the tendency to regression during follow-up. On the other hand, complete atrioventricular blocks created by radio-frequency energy are generally definitive and are associated with a junctional escape rhythm which is usually stable.

The role of the great arteries is to distribute and stock blood. Pulsatile discontinuous flow is transformed to a continuous flow system. The elastic properties of the aorta play a major role in these functions. It is generally agreed that changes in these elastic properties may lead to the development of left ventricular hypertrophy. The evaluation of the aorta has, until recently, depended on invasive hemodynamic and angiographic techniques. In addition, the measurement of pulse wave velocity, though useful, is a global and only an approximate method. Transoesophageal echocardiography (TEE) enables accurate measurement of the aortic diameter and its systolo-diastolic variations. The accuracy of these measurements has been validated in vitro and the reproducibility is much better than with previously used techniques. Previous studies have shown an improvement of the elastic properties of the great arteries with nitrate derivatives. In recent studies using TEE, isosorbide dinitrate caused dilatation of the descending thoracic aorta and thereby improved its elastic properties. The development of tonometry techniques in our department has resulted in the finding of excellent correlations between carotid and aortic pulse pressures measured non-invasively. The association of TEE and tonometry thereby provides a direct approach to the evaluation of aortic compliance. It has then become possible to study the effects of nitrate derivatives on the aortic compliance of elderly patients in whom it is the most reduced.

Echo Doppler makes a fundamental contribution to the non-invasive quantification of mitral valve disease. It enables calculation of gradients and of orifice surface area in mitral stenosis. The quantification of mitral insufficiency is also possible though more difficult: it is based upon the combination of semi-quantitative and quantitative methods, in particular the calculation of regurgitation fraction obtained by comparison of flow rates at different orifices in cases of pure regurgitation. Finally, the calculation of pulmonary artery pressures from a Doppler record in tricuspid and pulmonary insufficiency can be used to assess the effects of mitral valve disease on the pulmonary circulation. Echo Doppler thus provides a reliable non-invasive hemodynamic assessment of mitral valve disease and should lead to a reduction in the number of invasive investigations in this type of valve disease.

Objective: To assess the usefulness of pulsed Doppler echocardiography as a method of measuring the regurgitant fraction in patients with mitral regurgitation., Patients and Methods: Twenty controls and 27 patients with isolated mitral regurgitation underwent Doppler studies. In the patients the study was performed within 48 hours of cardiac catheterisation. Aortic outflow was measured in the centre of the aortic annulus, and mitral inflow was derived from the flow velocity at the tip of the leaflets and the area of the elliptical mitral opening. The regurgitant fraction was calculated as the difference between the two flows divided by the mtiral inflow., Results: In the 20 controls the two flows were almost identical (mitral inflow, 4.44 (SD 0.88) l/min; aortic outflow, 4.58 (SD 0.84) l/min), with a mean regurgitant fraction of 4.2 (SD 8.4)%. In patients with mitral regurgitation, the mitral inflow was significantly higher than the aortic outflow (8.8 (3.6) v 4.3 (1.1) l/min). In most patients the Doppler-derived regurgitant fraction (45.8 (19.2)%) accorded closely with the regurgitant fraction (41.3 (SD 17.8)%) determined by the haemodynamic technique., Conclusion: Pulsed Doppler echocardiography, with an instantaneous velocity-valve area method for calculating mitral inflow, reliably measured the severity of regurgitation in patients with mitral regurgitation.

The aim of this study was to evaluate the validity of Doppler echocardiographic evaluation of the regurgitant fraction in pure mitral insufficiency. The Doppler echocardiographic measurement of systemic flow was made at the level of the aortic ring, and the mitral flow by the method of integration of instantaneous flow proposed by Touche. In a preliminary study, we demonstrated a close correlation between forward aortic and mitral flow in 20 normal subjects (r = 0.94; SD = 0.31 l/mn; y = 0.98 x -0.004). We then studied a group of 38 patients with pure isolated mitral regurgitation. Five patients were excluded because of the poor quality of the echocardiographic documents. The hemodynamic regurgitant fraction was determined by measuring pulmonary flow by thermodilution and the left ventricular outflow by digitised angiography. The average Doppler and hemodynamic regurgitant fractions were 46.6 +/- 18% and 42 +/- 17% respectively. There was a close correlation between the Doppler and hemodynamic values (r = 0.91; SD = 7.8%; y = 0.97 x + 5.7). The correlations were also good between Doppler regurgitant fraction and the four angiographic grades of regurgitation (r = 0.88). A statistically significant difference was observed between the Doppler regurgitant fractions of Grades I and II and of Grades III and IV (p less than 0.001). In addition, the ratio of mitral VTI/aortic VTI gave a useful index of regurgitation in pure mitral insufficiency. When the ratio was greater than 1.3 the regurgitant fraction was over 40% with a sensitivity of 79% and a specificity of 86%. Finally, this study shows that pure, isolated mitral regurgitation can be evaluated by Doppler echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Complete atrioventricular block (AVB) following radiotherapy has been reported rarely, usually after high dose mediastinal irradiation for Hodgkin's disease or lung or breast carcinoma. We report six new cases of episodic complete infranodal AVB, requiring permanent pacemaker implantation. The mean age was 48-years old (ranging from 25-60) at the first Adams Stokes attack, mean delay was 12 years after irradiation (10-18), and mean radiation dose was 5,200 rads (4,000-6,500). All patients had abnormal interval electrocardiograms (right bundle branch block in two, left bundle branch block in three, alternating left and right bundle branch block in one). Electrocardiograms during the episode of AVB or Holter recordings were consistent with infranodal block in all patients; electrophysiological study performed in five patients confirmed infranodal AVB in four, and one was normal. Pericardial disease was constant, which included pericardial constriction in four patients. Two patients died after failure of pericardiectomy to improve congestive heart failure, due to epicardial, myocardial, and endocardial involvement. Noncardiac mediastinal lesions were present in four cases. Since this delayed complication may occur in patients of such age that the relation between the AVB and the chest irradiation is questionable, we propose the following etiologic criteria; high radiation dose (over 4,000 rads); delay of 10 years or more; abnormal interval tracings; pericardial involvement; and associated cardiac or mediastinal radiation-induced lesions.

The aim of this study was to assess the validity of mitral valve blood flow measured by pulsed Doppler echocardiography (PDE) with the sample volume positioned at the tips of the mitral leaflets. Thirty patients with a mean age of 38.4 years underwent calculation of transmitral blood flow: by Touche's method (A) in which the mitral orifice is assumed to be an ellipse with a constant long axis equal to the diameter of the mitral annulus and a variable short axis equal to the distance between the mitral leaflets measured on the M mode recording. The velocities are recorded by PDE with the sample volume at the tips of the mitral leaflets. The instantaneous cardiac output is equal to the surface multiplied by the instantaneous velocity. The integration of the instantaneous outputs throughout the whole of diastole by a computer programme provides the stroke volume; by a simplification of this method (B) which considers the short axis of the mitral ellipse to be constant and equal to the mean mitral valve leaflet separation measured from the M mode recording, and; by Hoit's method (C) which calculates mitral valve surface area from the M mode recording alone. The transmitral blood flow was calculated by these three methods and compared to the classical PDE aortic cardiac output measurement during the same examination, the accuracy of which has been previously demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of expanded polytetrafluorethylene membranes to attain bone regeneration around dental implants is described. Membranes discourage "non-desirable" cells form colonizing the healing site. These cells are essentially derived from gingival epithelium and gingival connective tissue. It is suggested that this procedure could be employed directly after tooth extraction.

Mitral flow velocity was studied during upright exercise on a bicycle ergometer using an original ultrasonic probe support device capable of maintaining a stable apical 4-chamber position. The Doppler sample volume was positioned at the tips of the mitral leaflets. Twelve men (mean age 25.3 +/- 5.8 years) without cardiac disease were studied. Exercise stress testing was performed with 30 watt increments of load of 3 minutes duration up to 120 watts. Mitral flow was recorded before exercise and at each increment of load until the exercise led to an average heart rate increase of 94%. The following changes were observed during exercise: a reduction in the duration of mitral flow (duration MF) and of the Duration MF/RR ratio; an increase in the mean mitral flow velocity of 154% at peak effort compared with basal values and the maximum A and E wave velocities which increased from T0 to T6 from 47 +/- 8.9 to 76 +/- 13 cm/s and from 62.4 +/- 13.1 to 107.8 +/- 14.9 cm/s respectively; the A/E ratio remained stable; mitral velocity time integrals (VTI) remained stable, indicating an increase in mitral surface area during exercise; the stability of the VTI at the A and E waves in absolute values but a mild increase of the A wave VTI/mitral VTI ratio, suggesting a slight increase in the role of atrial contraction during exercise. These results show that the increase in mitral flow velocity during upright exercise on a bicycle ergometer in healthy young adults is accompanied by a constant A/E ratio and mitral VTI which indicates that the mitral surface area increases on effort.

To assess the value of measuring the aortic regurgitant jet diameter at its origin by M-mode colour Doppler imaging, 82 patients with aortic regurgitation underwent, within 72 h of each other, colour Doppler examination and angiography. After excluding one patient without colour Doppler aortic regurgitation and five with a highly eccentric regurgitant jet, we found a close relationship between the jet diameter at its origin measured by M-mode colour Doppler and the angiographic grade of aortic regurgitation (r = 0.88). A jet diameter greater than or equal to 12 mm identified severe aortic regurgitation (grade III or IV) with a sensitivity of 86.4% and a specificity of 94.4%. In 38 patients, the jet diameter correlated well with the regurgitant fraction measured by a combined haemodynamic-angiographic method (r = 0.88). A jet diameter greater than or equal to 12 mm identified a regurgitant fraction greater than or equal to 40% with a sensitivity of 88.2% and a specificity of 95.2%. This study indicates that the size of the regurgitant jet diameter at its origin measured by M-mode colour Doppler provides a simple and useful measure of the severity of aortic regurgitation. It may allow differentiation between mild or moderate and severe aortic regurgitation and evaluation of regurgitant fraction.

End diastolic flow velocity just beneath the aortic isthmus was measured within 72 hours of cardiac catheterisation by pulsed Doppler echocardiography in 30 controls and 61 patients with aortic regurgitation. The end diastolic flow velocity was determined at the peak R wave on a simultaneously recorded electrocardiogram. In all controls there was no reverse flow at the end diastole beneath the aortic isthmus. In patients with aortic regurgitation the end diastolic flow velocity correlated well with the angiographic grade of regurgitation (r = 0.81) and regurgitant fraction (r = 0.82). The mean (SD) values were 6.3 (5.2), 12.2 (4.3), 22.1 (5.7), and 34.3 (9.3) cm/s for patients with regurgitant fraction of less than 20%, between 20% and 40%, between 41% and 60%, and greater than 60%, respectively. An end diastolic flow velocity of greater than 18 cm/s predicted a regurgitant fraction of greater than or equal to 40% with a sensitivity of 88.5% and a specificity of 96%. The study suggests that the pulsed Doppler derived end diastolic flow velocity is a useful index in the routine non-invasive assessment of the severity of aortic regurgitation.

Pulsed Doppler echocardiography was performed in 30 patients to assess the influence of mitral orifice area and velocity on the determination of mitral stroke volume and inflow. Aortic forward stroke volume and outflow were measured at the centre of the aortic annulus, and compared with mitral flow measurements calculated by three methods. Both mitral stroke volume and inflow derived from an instantaneous velocity-area method showed an excellent correlation with aortic flow measurements. The other two methods, which determined mitral stroke volume and inflow based on a mean mitral valve area and diastolic velocity integral, significantly underestimated mitral flow measurements. This study indicates that the instantaneous velocity-area method offers a reliable means for quantitating left ventricular inflow.

The aim of this study was to measure the changes in mitral and aortic blood flow induced by rate changes and different atrioventricular intervals in dual chamber pacemaker patients. Ten totally pacemaker dependant patients were studied under basal conditions, in double atrial and ventricular stimulation mode, by pulsed Doppler recordings of mitral and aortic flow, at three different pacing rates (80, 100 and 120/mn) and with three different atrioventricular intervals at each rate (short, 90 or 115 ms; medium, 165 or 190 ms; and long, 240 ms). The increase in pacing rate and prolongation of the atrioventricular interval significantly shortened the duration of mitral flow. Increasing the pacing rate induced a significant fall in stroke volume measured from the aortic flow. The optimal atrioventricular interval tended to shorten when the pacing rate was increased; a long atrioventricular interval had a deleterious effect on stroke volume compared with medium and short atrioventricular intervals; however, the difference between the short and medium atrioventricular intervals was not statistically significant even at 120 mn. These observations emphasise the hemodynamic advantages of shortening of the atrioventricular interval of dual chamber pacemakers when the pacing rate increases.

Arrhythmias are frequent and associated with a poor prognosis, especially when they arise from the ventricle. Although the correction of predisposing factors and improvement of hemodynamic conditions are essential, the use of antiarrhythmic drugs in this context poses problems. The treatment of even complex ventricular extrasystoles has not been shown to effectively prevent the serious arrhythmias responsible for sudden death. Depression of left ventricular function and: Or proarrhythmic effects of antiarrhythmic therapy in some patients, probably offset the benefits observed in others. The treatment of atrial arrhythmias remains traditional: reduction by drugs or electrotherapy and prevention of recurrences, or simply slowing the ventricular response. Sustained ventricular tachycardia and resuscitated ventricular fibrillation should be managed more aggressively, not by empirical antiarrhythmic treatment but by medical therapy guided by the results of electrophysiological studies, and, when this fails, by non-medical treatment: fulguration, implantable defibrillator, antiarrhythmic surgery, or even cardiac transplantation.

This Doppler echocardiographic study of patients with a dual chamber pacemaker was undertaken to assess the changes in mitral and aortic flow induced by passing from the double stimulation to the atrial detection mode. Thirteen patients totally dependent on ventricular pacing were examined and mitral and aortic blood flow recorded by pulsed wave Doppler. The chronology of left atrial contraction as assessed by the Doppler mitral A wave was measured with respect to the ventricular stimulation. The A wave was recorded on average 177 ms after the right atrial stimulation artefact. For an average AV delay of 168.8 ms and an identical pacing frequency, the passage from the double stimulation to the atrial detection mode led to left atrial contraction occurring on average 70 ms earlier with respect to ventricular stimulation, reflecting prolongation of the programmed AV delay related to the delay in detection of the sinus atrial wave. This earlier atrial systole shortened the total duration of mitral flow from 363 to 317 ms, decreased the early diastolic mitral flow and increased the atrial end diastolic flow; the stroke volume and cardiac output calculated from the aortic velocity time integral decreased significantly from 73 +/- 11 ml to 67 +/- 10 ml and 5.4 +/- 1.11/mn to 4.9 +/- 1.01/mn respectively. The initial parameters were restored (average 74 +/- 9 ml and 5.5 +/- 1.11/mn respectively) when the AV delay in the atrial detection mode was reduced by a value close to that of the calculated increase.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of an original ultrasonic transducer holder has made possible the recording of M mode and 2D echocardiography during exercise. Left ventricular function was studied during upright bicycle exercise in two groups: 10 trained athletes (Group A) and 10 normal subjects (Group B). All were 20 years of age. Satisfactory echocardiograms were obtained up to a mean heart rate of 180/mn which corresponded to an average work load of 180 W in Group B and 300 W in Group A. The cardiac output was comparable in the two groups up to a 180 W load, but in Group A a lower HR was compensated by a larger stroke volume (SV). The increase in SV in Group A was related to a greater LV end-diastolic dimension (LVEDD) during exercise, whereas the ejection fraction increased less than in the control group. During very strenuous exercise (Group A only) further increases in cardiac output were related mainly to an increased heart rate and to a lesser degree to increased LVEDD and ejection fraction.

Based on 8 cases, the authors study the mechanisms involved in post-traumatic enophthalmos and demonstrate that they result from an increase in orbital volume. There are no grounds to suggest that the disappearance of orbital fat is involved.

The correction of dento-facial deformities with Lefort I osteotomy are always accompanied by changes in soft tissue and skeleton. But, in many cases there is also modification of the low floor of the nose and profile changes. This clinical experience has been confirmed in the Laboratory on cadavre experimentation. Three deplacements have been studied: advancement of maxilla, inferior repositioning of maxilla and superior repositioning of maxilla. Often, Lefort I osteotomy is a complex association of these movements; modifications are also function of soft tissue. Operation must necessary provide theses technical modification for a real adaptation of the surgery. The surgical technique must therefore be adapted in order to obtain the best aesthetic result.

Ventricular arrhythmias may be the result of three mechanisms: abnormal automaticity, triggered activity complicating early or late after-depolarizations, and reentry by circular pathway or by reflection. These three fundamental mechanisms have been observed in the intact heart in experimental models of myocardial ischemia and digitalis intoxication. In man, the arguments in favor of a given mechanism are indirect and may be determined by their response to stimulation. It may be possible to state the following conclusions: (1) reentry is at the origin of ventricular fibrillation, certain ventricular tachycardias of bundle branch reentry and probably most chronic sustained ventricular tachycardias that are easily inducible; (2) the mechanism of certain other ventricular arrhythmias sustained remains unknown; (3) even when arrhythmias are associated with reentry, the triggering extrasystole can arise from a focal origin.

Cardiopulmonary bypass (CPB) may be a cause of myocardial damage in a small number of patients undergoing valve replacement (4 out of 1576 valve replacements). The responsibility of CPB can only be presumed when: the degree of myocardial dysfunction after surgery can be quantified, other causes of myocardial dysfunction are excluded. the type of valvular disease is taken into consideration. Variations in load after correction of certain lesions (mitral regurgitation) makes changes of LV systolic function difficult to interpret. The first case concerned a 23 year old patient operated for aortic regurgitation (Björk prosthesis) under local and general hypothermia and followed-up for 1 year after surgery. Ventricular extrasystoles and left bundle branch block were observed during surgery and radiological and echocardiographic LV dilatation persisted with deterioration of echographic, isotopic, haemodynamic and angiographic parameters of LV function: ejection fraction fell from 62% before surgery to 35% with diffuse hypokinesia and persistent LV dilatation (191 vs 188 ml). In the absence of prosthetic valve dysfunction, associated valve lesions or coronary artery disease, LV deterioration was attributed to CPB and inadequate myocardial protection. In two other cases (60 and 62 years) correction of aortic stenosis (Starr 1260) with coronary perfusion was followed by cardiac failure with left bundle branch block, deterioration of LV function, and death after 3 years in one case and precarious survival at 10 years in the other. In a fourth case (mixed mitral valve disease corrected by a Starr prosthesis under aortic clamping), the variation of cardiac load before and after surgery made changes in LV function difficult to interpret. (ABSTRACT TRUNCATED AT 250 WORDS)

To assess the feasibility and efficacy of percutaneous mitral commissurotomy (PMC), the procedure was attempted in 200 patients with severe mitral stenosis. There were 154 women and 46 men, their mean age was 43 +/- 16 years (range 13 to 79) and 15 were older than 70 years of age. Forty-four had had previous surgical commissurotomy. Forty were in New York Heart Association class II, 152 in class III and 8 in class IV. In regard to valvular anatomy, 67 had calcified valves, 58 had pliable valves and only mild subvalvular disease, and 75 had flexible valves but extensive subvalvular disease. Grade 1+ mitral regurgitation was present in 62 and grade 2+ in 2. In 11 patients the procedure was discontinued because of complications in 3 and technical failure in 8. Six of the 8 technical failures occurred during the first 15 attempts. Effective PMC was performed in 189 patients using 1 balloon in 23 and 2 balloons in 166. After PMC, there was a significant improvement in mean left atrial pressure (21 +/- 7 to 12 +/- 5 mm Hg, p less than 0.0001), mean mitral gradient (16 +/- 6 to 6 +/- 2 mm Hg, p less than 0.0001), cardiac index (2.6 +/- 0.8 to 3.1 +/- 0.8 liters/min/m2, p less than 0.001) and valve area assessed by hemodynamics (1.1 +/- 0.3 to 2.2 +/- 0.5 cm2, p less than 0.0001) and 2-dimensional echocardiography (1 +/- 0.3 to 1.9 +/- 0.4 cm2, p less than 0.0001). No patient died. Embolism occurred in 8 (4%), with no further sequelae. Sixteen (8%) had atrial septal defect detected by oxymetry.(ABSTRACT TRUNCATED AT 250 WORDS)

In order to evaluate the effectiveness and risks of percutaneous mitral commissurotomy (PMC), we tried this procedure in 130 patients. Nine attempts were unsuccessful due to pre-PMC complications (haemopericardium 2, air embolism 1) or to technical failure (6 cases, 5 of which occurred in the first 15 attempts). PMC could be performed in 121 patients: 88 women and 33 men aged from 13 to 79 years (mean 42 + 15 years); 22 patients had previously been operated upon, 5 had a history of embolism, 99 were in functional stage III or IV. Echocardiography divided these patients into 3 groups: 29 had calcified leaflets (group 1), 42 had flexible leaflets and little alteration of the subvalvar system (group 2), and 49 had flexible leaflets with alteration of the subvalvar system (group 3). Mitral regurgitation grade 1/4 was present in 32 cases. PMC was performed with one balloon (Trefoil 3 x 12 mm) in 14 patients and therafter with two balloons (Trefoil 3 x 10 mm plus conventional 15 or 19 mm balloon) in 107 patients. PMC resulted in significant improvement in haemodynamic values: the mean capillary pressure fell from 20 +/- 7 to 11 +/- 5 mmHg (p less than 0.0001) and the mean mitral gradient from 16 +/- 6 to 6 +/- 2 mmHg (p less than 0.0001), while the cardiac index rose from 2.7 +/- 0.6 to 3.1 +/- 0.7 l/mn/m2 (p less than 0.001) and the mitral valve area (MVA) from 1.1 +/- 0.2 to 2.2 +/- 0.5 cm2 (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

The case of a 77-year old woman who died of refractory pulmonary oedema 36 hours after percutaneous valvuloplasty for tight calcified aortic valve stenosis is reported. Post-mortem examination showed satisfactory opening of the aortic orifice but also rupture of an aberrant chorda which crossed the outflow tract below the aortic sigmoid valves, between the mitral valve and the interventricular septum. This case suggests that before all aortic valvuloplasties the absence of aberrant chorda or suspicious subaortic acceleration should be confirmed by Doppler echocardiography; moreover, during the procedure the balloon should not be inserted too deeply into the left ventricle.

The diagnostic of ganglionnary invasion in oral cancer is established throughout the histological investigation practiced during the operation. This histological inquiry has to be rigorous and logical, in conformity with the anatomical particularities of the drainage tubes of the oral mucous. The accurate execution of this diagnostical strategy applied to the ganglionnary invasion improves the prognostic but requires a good logistic support.

ECG gated 201Tl scintigraphy was compared to non gated images for detecting 2-3 vessel disease 1-3 months after a first uncomplicated myocardial infarction. In all, 111 patients on anti anginal treatment underwent coronary arteriography and stress thallium imaging; 39 showed single vessel disease (SVD), and 72 multivessel disease (MVD). Sensitivity of black and white analog images was 82% for SVD and 8% for MVD. Sensitivity of computerized colored static images was 87% for SVD and 33% for MVD. For gated images, sensitivity was 100% and 92% in patients with SVD and MVD respectively. Specificity for detecting MVD was 95% for black and white images, 77% for computerized colored static images, and 69% for ECG gated images. Thus, ECG gated exercise 201TL scintigraphy is useful for predicting the extent of coronary artery disease 1-3 months after myocardial infarction in patients on anti anginal therapy.

The large frequency of arrhythmias and conduction disorders in the course of Steinert's myotonic dystrophy is well known; most of the time, the muscle disease is already known when the heart disease is discovered. The authors report three cases of young subjects (2, 31 and 35 years) in whom an atrial flutter without obvious etiology preceded by several years (14, 2.5 and 2 years) the diagnosis of muscular disease. On this occasion, the characteristics of the heart involvement in Steinert's disease are reminded: large frequency of atrial and also ventricular rhythm disorders, distalic conduction disorders. Our cases emphasize the importance of diagnosing Steinert's disease by clinical examination, electromyography and neuro-muscular biopsy in front of a rhythm disorder--especially atrial flutter--or an interventricular conduction disorders occurring, without obvious etiology, in a young subject.

The results of percutaneous mitral valvuloplasty in 5 adult patients with mitral stenosis are presented. The average age was 55 years (37-72 years); 4 patients were in functional Class III and 1 in Class IV. The three oldest patients were in atrial fibrillation, and 2 of them had severe valvular and subvalvular lesions. Valvuloplasty was carried out with a "Trefoil" balloon (3 X 12 mm; effective cross sectional area at maximal inflation: 3.8 cm2). The procedure was successful in 4 patients. In the other patient, it was not possible to position the balloon across the stenotic valve. After valvuloplasty, the mean mitral gradient decreased (14 +/- 5 to 6 +/- 2 mmHg, p less than 0.05) without a significant change in cardiac index (2.9 +/- 0.5 vs 2.7 +/- 0.4 l/mn/m2; NS): this indicated an increased mitral valve surface area (1.1 +/- 0.2 to 1.8 +/- 0.05 cm2, p less than 0.05). In parallel, echocardiographic measurements of mitral valve surface area increased from 0.9 +/- 0.2 to 1.8 +/- 0.3 cm2, p less than 0.05, and Doppler pressure halt time fell from 220 +/- 50 to 116 +/- 13 ms, p less than 0.05. There were no operative complications and, in particular, no resulting angiographic mitral regurgitation. These preliminary results suggest that percutaneous mitral valvuloplasty may be a valuable alternative therapeutic procedure to surgery in selected patients.

A total of 546 patients with severe aortic stenosis (AS) were retrospectively reviewed to assess the efficacy of percutaneous transluminal valvuloplasty (PTV) and valve replacement (VR). Of these, 490 underwent VR between 1968 and 1986 (mean age 62 +/- 12 years, 71.7% were in NYHA class III or IV), 68.8% received mechanical prostheses, and in 11.8% a bypass graft was associated. The operative mortality was 6.9% (4% since 1983). The mean follow-up was 57.6 months. The actuarial survival rate was 77% at five years, 60% at 10 years, and 40% at 15 years. Over 70 years of age, operative mortality was 6.2% since 1983, and the actuarial survival rate was 67.5% at five years. From February 1986 to May 1987, PTV was attempted in 56 patients and was effective in 52 patients (mean age 79 +/- 5 years, 93% in Class III or IV). Immediate mortality was 7.1%. The morbidity was due to tamponade (1.8%), myocardial infarction (3.6%), vascular trauma (5.3%), or cerebrovascular accident (9%). Forty three patients were followed after PTV (mean value 4.2 +/- 3, range 1-14 months): 12 patients (28%) died and 46% were functionally improved in NYHA Class II. PTV significantly improved the aortic valve area as shown by haemodynamics (0.49-0.75 cm2; P less than 0.0001) and these findings were corroborated by Doppler study (0.46-0.70 cm2, P less than 0.001). In conclusion, this series shows that surgery provides satisfactory results in AS with a low mortality and good long-term results, even in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

A 23-year-old woman with systemic lupus erythematosus was found to have severe pulmonary hypertension with secondary patency of the foramen ovale. Infusion of hydralazine increased the basal right-to-left shunt and resulted in a dramatic fall in arterial oxygen pressure, with subsequent irreversible cardiovascular collapse. Vasodilator therapy appears to be hazardous in patients with severe pulmonary hypertension and patent foramen ovale.

Described by Obwegeser in 1957, horizontal osteotomy of the chin is one of the simplest osteotomies performed on the face. For a long time the insertion of an implant has been preferred to this osteotomy due to the difficulties involved in maintaining it in a good position. The use of preformed Paulus plates of different sizes resolves the problems of contention and ensure perfect stability of the osteomuscular fragment, guaranteeing a permanent result.

The characteristic features and principal results of the 5 large-scale randomised therapeutic trials (GISSI, ISIS 2, ASSET, AIMS, ISAM), each including over 1000 patients, designed to evaluate the effects of thrombolysis on mortality in myocardial infarction, are reviewed. The methodologies are very different, which prevents comparison of results. The thrombolytic therapy significantly reduced hospital mortality in all the trials except ISAM. Early institution of therapy gave better results but one trial (ISIS 2) showed persistence of a significant benefit in patients treated late up to the 24th hour and in the most elderly groups of patients (up to and over 70 years of age). The benefits obtained during the hospital phase were maintained at medium term. The tolerance was satisfactory, the frequency of complications being comparable in all the trials. The association of aspirin therapy significantly reduced mortality and occurrence of myocardial infarction in the ISIS 2 trial and would seem to be therefore a recommended association with streptokinase and probably with other thrombolytic drugs. Other trials are needed to compare the efficacy of the different thrombolytic agents in reducing patient mortality.

Six cases of this rare association (7 to 10 p. 100 of Takayasu's disease) are reported. The authors also review 73 previously reported cases. The valvular lesion is usually detected secondarily during follow-up (2/3 of cases), but is observed at the same time as the arterial disease in about 1 out of 5 cases. In rare cases, it may be the presenting feature before the vascular disease becomes clinically apparent. Quantification of the regurgitation may be difficult because of stenosis of the thoracic aorta and the supra aortic vessels. In some cases it is severe and poorly tolerated but has no particular distinguishing features apart from the incidence of aortic wall calcification (ascending aorta to all of the aortic arch). Twenty five anatomical observations (operative or autopsy) are sufficiently well documented to show the mechanism of the aortic incompetence. It is caused by an inflammatory aortitis: valvular lesions were found in 2/3 of cases but other causes may be observed, dilatation of the aortic ring (1 out of 4 cases), disunion of the commissures (1 out of 4 cases) and changes in aortic compliance causing systolic hypertension. Aortic valve replacement is rare (11 cases including 3 personal cases) and sometimes completed by resection of an aneurysmal ascending aorta.

Thyroid iodine content (TIC) was measured by x-ray fluorescence in 68 patients who had received amiodarone treatment for varying intervals (1 g/week for 1-120 months). Thirty-six patients were euthyroid; the mean TIC of the patients (n = 15), who had been treated for less than 12 months was 30 +/- 19 (+/- SD) mg, twice the normal mean value (14.6 +/- 5.0 mg), and it was 39 +/- 17 mg in those (n = 16) who had been treated for 12-60 months and 29 +/- 6 mg in those (n = 5) who had been treated longer (greater than 60 months). Nineteen patients were hyperthyroid and had elevated TIC values. Of them, 6 patients had a goiter; their TIC (50 +/- 19 mg) was not significantly different from that of the hyperthyroid patients with no goiter (55 +/- 29 mg), but they became hyperthyroid more rapidly. Thirteen patients were hypothyroid; none had TIC values above the normal range, and it was below 2.5 mg in 5 patients. A sequential study was undertaken in 11 euthyroid patients who had no detectable antithyroid antibodies. TIC did not increase during treatment in 2 patients; both developed hypothyroidism, which was transient in 1 despite continuation of amiodarone treatment. The TIC initially increased during amiodarone treatment in the other 9 patients, leveling off at the end of the first year. The TIC rose well above the upper limit of the normal range in 4 patients, of whom 2 became hyperthyroid during the second year of treatment. TIC remained within the normal range in the other 5 patients, of whom 3 became hypothyroid after 12-24 months of treatment (1 subclinical, 2 overt). Although the TIC was significantly higher in the patients with hyperthyroidism than in the patients who remained euthyroid, the TIC test cannot be used to predict the occurrence of hyperthyroidism. The latter must be diagnosed on the basis of clinical symptoms and a frank elevation of serum thyroid hormone levels. Conversely, patients whose TIC values do not increase during treatment or remain within the normal range should be considered at risk for hypothyroidism.

The aetiology and evolution of chronic infranodal atrioventricular block (AVB) of young patients are not well known: are they the first sign of subclinical myocardial disease which can only be diagnosed by long term follow-up or do they represent isolated degenerative disease of the conduction tissue (Lenegre's disease)? Eighteen patients (15 men, 3 women) aged 25 to 49 years (average 41.5 years) were followed up for periods of 2 to 20 years (average 7.33 years) after pacemaker implantation for syncopal AVB. Follow-up was focused on the evolution of the conduction defects and the cardiovascular status. The patients were divided into two groups at the initial assessment: Group I: 15 patients with documented AVB; Group II: 3 patients in whom all basal recordings showed sinus rhythm (SR). Apart from one patient with an early non-ischaemic dilated cardiomyopathy, there was no previous cardiovascular disease. There was no history of ischaemic heart disease, drug effects, infection or inflammation in favour of an acute AVB. Three patients had permanent AVB, either 2nd degree with bundle branch block (N = 2) or 3rd degree block (N = 1). The other 15 patients were in sinus rhythm with bundle branch block: left bundle branch block (LBBB) in 5 cases, right bundle branch block (RBBB) in 3 cases; RBBB with left anterior hemiblock in 5 cases, RBBB and left posterior hemiblock in 2 cases. Paroxysmal AVB was recorded in 12 of these 15 patients on at least one occasion.(ABSTRACT TRUNCATED AT 250 WORDS)

163 patients aged from 27 to 70 years (mean 52 +/- 10 years), including 152 men and 11 women, received a thrombolytic treatment within the first 6 hours (mean 192 +/- 73 mn) of a myocardial infarction. 61 patients received streptokinase (SK) intravenously (group 1), 64 patients, single-chain rt-PA (group 2), 11 patients, two-chain rt-PA (group 3), 11 patients, rt-PA followed by intracoronary streptokinase (group 4), and 16 patients, acyl enzyme (group 5). In addition, all patients had heparin and 86 (53%) had aspirin. Immediately after thrombolysis, coronary arteriography was performed in 95 patients (58%), and this was followed by transluminal angioplasty in 49 of them (30%). The infarction was either anterior (n = 81) or inferior (n = 78) or lateral (n = 4). No fatal or neurological bleeding occurred. 17 haemorrhagic complications were observed; 5 of these (3%) were severe, requiring blood transfusion and, in 1 case, surgery; 12 were significant (7.4%) and produced changes in haematocrit. Nine of the 17 haemorrhages were associated with catheterization and localized to the site of arterial puncture. Severe bleeding occurred in patients treated with intravenous SK (3/61) or with rt-PA followed by intracoronary SK (2/11). There was a significant difference in the incidence of spontaneous bleeding between the SK group (4/61) and the single-chain rt-PA group (0/64; p less than 0.05). In the latter group, the minimum fibrinogen level was lower in patients who had a haemorrhagic complication.(ABSTRACT TRUNCATED AT 250 WORDS)

The advantages of partial anterior chondrotomy for correction of protruding ears are discussed and detailed explanations provided with respect to the different surgical stages involved. The simple postoperative course and efficacy of this procedure are emphasized.

Reconstruction of the vermilion border in three patients with maxillofacial bullet wounds was by use of a tongue flap. The interest of a bifid flap is stressed, this providing a border capable of allowing almost normal opening of the mouth, and possessing the advantage of its removal from the ventral surface giving an appearance close to that of the uninjured commissural vermilion.