Biomedical subjects
Publications and source records attributed to J Valty.
The authors report a case of severe constrictive pericarditis occurring 6 weeks after coronary bypass surgery and in the absence of any other predisposing factor. The diagnosis was confirmed by CT scan and cardiac catheterisation which showed signs of a diastole. The patient died despite early surgical reoperation because of the severity of the pericardial fibrosis.
UNLABELLED: The aim was to find an objective indicator in order to evaluate white coat effect (WE). The first hour average values after placing an ambulatory blood pressure recorder (15 mn intervals) were compared to those of the 4 following hours of diurnal activity. A first hour systolic arterial blood pressure (SBP 1H) increase of 10 mmHg or more was considered as an ambulatory WE positive (AWE+) and was compared to clinical WE (CWE). CWE+ was observed in 78 pts and AWE+ in 72 among a group of 172 unselected pts referred for hypertension. RESULTS: the correlation between AWE and CWE is weak (r = 0.49) but significant (p < 0.001). There was no difference between the two groups in age, sex, clinical blood pressure, heart rate or ambulatory BP after the first hour (table). There was a significant difference in SBP between the 2 groups (p < 0.001) during the first hour only. [table: see text] CONCLUSION: Ambulatory blood pressure recording is able to recognize and evaluate the white coat effect. We suggest to consider independently the first hour of each recording and to compare it with the mean pressure measured during the period of diurnal activity.
The authors report the case of puerperal thrombosis of the right ovarian vein complicated by recurrent small pulmonary emboli in a 32 year old woman. The clinical features of this rare condition are reviewed. The echographic, angiographic and CT scan and magnetic resonance imaging abnormalities are described. The authors underline the value of non-invasive radiological investigations for early diagnosis. The patient was rapidly improved by medical therapy with antibiotics and heparin.
The renin-angiotensin and cardiac natriuretic systems were studied by measuring plasma renin activity, plasma concentrations of active renin, angiotensinogen, atrial natriuretic hormone and urinary cyclic GMP in 37 patients with moderate to severe cardiac failure. The plasma sodium and osmolality were chosen as markers of hydroelectrolytic imbalance and plasma concentrations of préalbumin and retinol-binding protein as indicators of the degree of hepatocellular dysfunction. Plasma renin activity (PRA) plasma concentration of active renin, atrial natriuretic hormone and urinary cyclic GMP were higher in patients in NYHA Class IV than in those in Classes II-III, whilst plasma sodium, angiotensinogen, prealbumin and retinol-binding protein concentrations were lower in Class IV patients than in patients in Classes II-III. The plasma angiotensinogen concentrations were negatively correlated with PRA (r = -0.41, p less than 0.02), active renin (r = -0.45, p = 0.005), the atrial natriuretic factor (r = -0.36, p less than 0.05) and positively correlated with prealbumin (r = 0.54, p less than 0.001) and retinol-binding protein (r = 0.60, p less than 0.0001). In NYHA Class IV patients the decreased circulating renin substrate led to an underestimation of plasma concentrations of active renin by measurement of PRA. On the other hand, direct radio-immunometric measurement of active renin allows true estimation of circulating active renin, independently of plasma angiotensinogen concentrations and thereby reliably reflects activation of the renin system. The serum sodium was negatively correlated with active renin (r = -0.66, p less than 0.0001) in these patients not receiving converting enzyme inhibitors.(ABSTRACT TRUNCATED AT 250 WORDS)
Abnormalities of myocardial metabolism during acute rejection may be due to ischemia to primary metabolic changes related to rejection. An experimental study of heterotopic cardiac transplantation in the rat was undertaken to study myocardial mitochondrial oxidation during acute rejection. The receivers were Lewis rats and the donors Fischer (FL: allograft) or Lewis (LL: isograft) rats. The oxygen consumption of the mitochondria (VO2m) isolated from the transplanted and native hearts was measured by oxygraphy six days after transplantation. Using maleate and glutamate substrates, the VO2m of transplanted hearts was significantly lower than that of native hearts in the two groups of rats (FL, p less than 0.01; LL, p less than 0.01). In addition, the VO2m of FL allograft transplanted hearts was significantly lower than in the LL rats (30 +/- 9 vs 100 +/- 15 nanoatoms of oxygen/min.mg/prot, p less than 0.01) as was the VO2m of the native hearts (FL: 106 +/- 23 vs LL: 164 +/- 26, p less than 0.02). The respiratory control ratio (RCR) was significantly lower in the transplanted than in the native hearts in both the FL and LL groups (p less than 0.05 and p less than 0.01 respectively). The comparison of the RCR in the two groups (FL vs LL) showed no significant difference for transplanted or native hearts. Electron microscopy of transplanted (rejected or not) and native hearts showed no morphological abnormality of the mitochondria. The lower VO2m of the allograft group indicates a disturbance in the mitochondrial respiratory pathway during acute rejection.(ABSTRACT TRUNCATED AT 250 WORDS)
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A multicentre retrospective study of 467 cases of operated aortic valve disease was undertaken to define the indications of coronary arteriography in the pre-operative work-up. Significant coronary artery disease was present in 15% of all cases or, more precisely, in 17% of cases with angina and in 8% when investigation was only routine. Coronary artery disease was more frequent in males, in patients with clinical or electrical evidence of previous myocardial infarction, in patients with ST-T wave changes, and when angina was severe (more than one attack per day). None of these factors was specific. It is therefore difficult to limit coronary arteriography to these patients or there would be a risk of missing significant lesions in a small number of cases. It is important to give the surgeon all the necessary information before aortic valve replacement and so coronary arteriography should be widely practiced in this context. However exceptions may be made for young patients and also those in congestive cardiac failure in whom coronary arteriography represents an unnecessary risk before surgery.
Combined surgery on the valves and on the coronary arteries by bypass grafts has been carried out on 27 consecutive patients (1970 to 1976) and involved 18 aortic valve replacements, 8 mitral valve replacements, and one double mitro-aortic replacement; the mean duration of extra-corporeal circulation (145 mn) was significantly higher than that for valve replacements alone carried out during the same period (p less than 0.01). The five deaths occurring in hospital (18.5%) all occurred in the aortic valve group, and were amongst the first 15 cases operated on (1970 to 1974). The 4 post-mortem studies carried out showed similar findings, namely myocardial infarction and significant coronary lesions which had not been bypassed. Two secondary deaths due to infective complications occurred in the first six months. The 17 patients who were followed up after surgery and had a mean follow-up period of 24 months, were all substantially improved by comparison with their pre-operative state, despite certain complications affecting either the valves (1 requiring re-operation) or the coronary arteries (3 infarcts). The indications for coronary arteriography, which are related to the indications for surgery, are being enlarged so that they will include the majority of patients operated on excluding those of more than 65 to 70 years of age and also those aged less than 40 years who have no risk factors for atherosclerosis and no clinical or electrocardiographic signs suggesting a coronary lesion. A study of the operative risk factors has shown the importance of unsuspected coronary lesions, and would appear to indicate correction of all valvular and coronary lesions seen at the time of operation.
1 188 mitral commissurotomies were carried out between 1962 and 1976, 37 of them (3.1%) being under direct vision. The two operative deaths (5.4%) occurred early in the series. Longer term follow-up showed that 3 cases died secondarily, and 3 had revision surgery. The main complication was mitral incompetence (51% of operated cases had a systolic murmur). The varying indications and results are presented; these justify a prospective study, but not a recommendation for the systematic adoption of mitral commissurotomy by an open heart technique.
The exercice electrocardiogram, carried out in 160 normal subjects, has allowed us to witness the physiological mechanisms of adaptation to exercise as a function of age and sex. The relationship between systolic arterial pressure (SAP) and cardiac rate (CR) is very narrow (R = 0.97), and is a linear function. Its slope increases with age in both sexes, and differs significantly in the male and female (P less than 0.001). Systolic pressure is related to the relative cardiac rate (CR%) by the formula SAP = 1.55.CR% + 70.
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A prospective study into the aetiology of presumed primary non-obstructive cardiomyopathy was carried out in 57 patients who had no lesions of the trunk of the coronary artery; one case of haemochromatosis and one of amyloidosis were found. Excluding these two cases of cardiomyopathy which were in fact secondary, most of the others were associated with manifestations or with complications of myocardial diseases (two pulmonary emboli and one case of jaundice) or pathology associated with it. Investigation into possible infection, biochemical abnormalities and dietary indiscretion (alcohol, colza oil), were unfruitful. Electromyographic changes of the "myositic" type were very common. The bicycle ergometry test was often interrupted through fatiguing of the peripheral muscles. These findings suggest that the muscular abnormalities may not be limited to the heart. The cost of an enquiry of this type has been investigated.
Out of 989 cases with a ball-valve prosthesis, 66 have been reoperated (6.7%). 2.9% of the cases reviewed annually have thus been reoperated. The main indications for reoperation were displacement (75.5%), malfunction (10.5%) which was related to a failure of the material of the prosthesis or to the deposition of fibrinous plaques, and associated lesions (14%) which were valvular, coronary or myocardial. There were multiple complications in 36 patients. The operative mortality was 31.8% (21.7% over the last two years). On statistical analysis, the significant risk factors were a previous history of bacterial endocarditis, grouping in Class IV of the NYHA classification, enlargement of the QRS complex (0.12 s), urgency of reoperation, and prolonged extracorporeal circulation (2 hours). The rapid fall in survival time was due in part to late deaths (16 patients). By way of contrast, the clinical result was satisfactory in 71% of the survivors. Analysis of the causes of failures has lead to a search for ways of preventing the necessity for reoperation.
100 patients (median age 79 years) were given anticoagulant therapy (ACT) for a period of time averaging 5 years 3 months (522 follow-up years).--Out of 3 522 Quick tests, converted into prothrombin times and all carried out in the same laboratory, the prothrombin time was at or less than 32% in 60.5%, and 34% in 69.6% of the tests.--The mean therapeutic doses were less than 27% of those for adults, and were decreased by 3 mg of phenindione per year over the age of 75, only the actively treated cases being retained.--The risks are the same as those for the middle-aged adult. They depend more on the quality of the investigations than upon age. In the group which has been studied, slight or frank haemorrhagic complications (0.05/year/patient) were the result of a demonstrable overdosage in only one case in four. They were not responsable for any deaths in this series.--because of the referral patterns, the patients studied consisted of 79 with ischaemic heart disease, 27 with peripheral vascular disease, 9 cerebrovascular accidents, and 6 with thrombo-emoblic problems, not counting the 23 complications during the course of the study. In those patients with ischaemic heart disease, well-regulated anticoagulant treatment was associated with a favourable clinical course, and the correlation was significant.--there is not argument against the administering of a full and prolonged course of ACT to a patient of more than 75 years of age.
The importance of the echocardiogram in a study of mitral disorders has been analysed by examining 107 echocardiograms set against a clinical examination, an investigation of haemodynamic function (57), left-sided angiography (42), and/or examination at the time of operation (40). This study confirms the great diagnostic value of the echocardiographic findings in mitral stenosis (56 patients): the amplitude DE, the slope EF, the percentage of mid-diastolic closure, the echo from the valves, and the dimension of the left atria (P less than 0.001). This association remains valid if there is mitral incomptence as well as stenosis, or if there is also an aortic lesion, provided all the parameters are used. The degree of stenosis of the mitral orifice cannot be determined with sufficient certainty to allow surgical exploration to be undertaken solely on echocardiographic results, however the patients are selected (sinus rhythm, absence of calcification, mobile valve...). The echocardiographic diagnosis of the 17 cases of mitral incompetence was incomplete (except for rupture of the chords); the volume of the regurgitation is poorly appreciated.
Between May 1963 and December 1976, 889 patients underwent single valve aortic replacement by prosthesis. Hospital (30 day) mortality fell, with an exponential decrease (r = 0.94, p less than 0.01) to 4 per cent in 1976. Early risk factors are studied, taking into account the changes affecting them respectively over the time period considered. The average age of the patients increased but did not significantly affect operative mortality. Cardio-thoracic ratio, sex and the duration of extracorporeal circulation had little or no prognostic value. Only classification in class IV of the N.Y.H.A. and the type of valvular disease (severe incompetence) were of clearly pejorative significance. Most deaths occurred early in a context of signs of poor cardiac output, severe disturbances of ventricular rhythym, visceral (digestive) syndromes and/or thrombotic complications. They were characterised at autopsy by sub-endocardial haemorrhagic lesions. The prevalence of these lesions and that of early deaths appeared to decrease with techniques for myocardial protection during the operation.
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A long term evaluation of prosthetic replacement of the aortic valve by various types of prosthesis has been carried out; 530 patients from various centres of cardiology were studied. The average annual mortality after the first two postoperative years was about 2.5% and half of the patients undergoing surgery were still alive after 10 years. The functional improvement is usually marked and is generally to be expected, although with an increased risk, even in patients who underwent surgery at stage IV of the NYHA classification. In this study, the prostheses which were associated with the best long term results were the Starr-Edwards 1260, the Smeloff-Cutter, and the Björk. The commonest complications after the first month were dehiscence of the prosthesis (11.8%), thromboembolic episodes (11.2%), coronary complicatons (11.1%) and cardiac failure (7.1%). The most serious is infection of the prosthesis, which is almost invariably fatal. Deterioration in the substance of the prosthesis has become very rare, but there must be reservations in this respect with the SE2400, which has still not been in use long enough. Revision operations were carried out on 7.6% of the survivors at one month, with a mortality of 18.4%. Sudden death remains a constant threat. A study of the actuarial survival graphs for operated and non-operated cases shows that surgery should be advised in all poorly tolerated valve defects, and even for an uncomplicated tight aortic stenosis. Bearing in mind the progressive lowering of operative mortality, surgical treatment is also justified in cases with marked or gross aortic incompetence which is well tolerated if flow-up studies show a progressive increase in cardiac volume.