Marcel Baudouy

Association Between Thrombolytic Treatment and the Prognosis of Hemodynamically Stable Patients With Major Pulmonary Embolism

Background Thrombolytic treatment has been shown to accelerate resolution of major pulmonary embolism and lead to a rapid improvement of right-side hemodynamics. However, the association between these favorable effects and the clinical outcome of patients who have no severe hemodynamic compromise at presentation remains unknown. Methods and Results The present multicenter registry included 719 consecutive patients with major pulmonary embolism according to clinical, echocardiographic, scintigraphic, and cardiac catheterization criteria. Symptom onset was acute (<48 hours) in 63% of patients. All patients were hemodynamically stable (ie, without evidence of cardiogenic shock) at presentation. Primary thrombolytic treatment (within 24 hours of diagnosis) was given to 169 patients (23.5%), whereas the remaining 550 patients were initially treated with heparin alone. Overall 30-day mortality was significantly lower in the patients who received thrombolytic agents (4.7 versus 11.1%, P=.016). Clinical factors a...

Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment.

BACKGROUND AND OBJECTIVE In patients presenting with pulmonary embolism (PE), echocardiography, in some cases, reveals mobile clots in right heart (RH) cavities. How these clots evolve after treatment, in particular after thrombolytic treatment (TT), is unknown. We sought to determine the outcome of these mobile clots in the RH during TT. METHODS AND RESULTS Of a series of 343 patients who had been hospitalized for PE in our department, echocardiography performed on hospital admittance showed a mobile clot in the RH in 18 patients (mobile clot incidence, 5.2%). This subgroup of 18 patients presented with a more severe form of PE than the 325 patients without mobile clots in the RH. In our series, 16 patients were treated with thrombolytic agents. Close echocardiography monitoring showed the outcomes of these mobile clots during and after TT. In 50% of cases, the clot disappeared rapidly in < 2 h after the end of TT. In 50% of the remaining cases, the clot disappeared later, half within 12 h following the completion of TT, and the other half within 24 h. All patients were alive on day 30 without any clinical sequellae. CONCLUSION In these particular forms of PE with mobile clots in the RH, the short time lag required to disperse the clot after TT makes it imperative to delay any decision about new aggressive therapy.

Selected ReportsMobile Thrombi of the Right Heart in Pulmonary Embolism: Delayed Disappearance After Thrombolytic Treatment

BACKGROUND AND OBJECTIVE In patients presenting with pulmonary embolism (PE), echocardiography, in some cases, reveals mobile clots in right heart (RH) cavities. How these clots evolve after treatment, in particular after thrombolytic treatment (TT), is unknown. We sought to determine the outcome of these mobile clots in the RH during TT. METHODS AND RESULTS Of a series of 343 patients who had been hospitalized for PE in our department, echocardiography performed on hospital admittance showed a mobile clot in the RH in 18 patients (mobile clot incidence, 5.2%). This subgroup of 18 patients presented with a more severe form of PE than the 325 patients without mobile clots in the RH. In our series, 16 patients were treated with thrombolytic agents. Close echocardiography monitoring showed the outcomes of these mobile clots during and after TT. In 50% of cases, the clot disappeared rapidly in < 2 h after the end of TT. In 50% of the remaining cases, the clot disappeared later, half within 12 h following the completion of TT, and the other half within 24 h. All patients were alive on day 30 without any clinical sequellae. CONCLUSION In these particular forms of PE with mobile clots in the RH, the short time lag required to disperse the clot after TT makes it imperative to delay any decision about new aggressive therapy.

Interatrial Conduction in Patients Undergoing AV Stimulation: Effects of Increasing Right Atrial Stimulation Rate

To evaluate the frequency of spontaneous or rate dependent interatrial blocks, the interatrial conduction time (IACT) was studied on 100 consecutive patients (mean age 78.3 ±7.8 years) during a transvenous dual chamber pacemaker implant. The spontaneous interatrial conduction time (SIACT) was measured from the intrinsic deflection (ID) of the unipolar right atrial signal to the ID of the left atrial signal recorded in a bipoiar way by an esophageal lead. The paced interatrial conduction time (PIACT) was measured from the stimulus artifact to the left atrial ID, when the atrium was paced at a slightly higher rate than the spontaneous rate and during incremental atrial pacing. From these measurements, the maximum increase ofPIACT (MIPIACT) was deduced. In this elderly population, the PIACT was similar (117 ± 26.9 msec) to the data in the literature. However, there were large interindividual variations that were also found in SIACT. We found a close correlation between SIACT and PIACT (P < 0.0001). PIACT was on average 50 msec longer than SIACT. SIACT increased with age (P < 0.03). The MIPIACT was 15.3 ± 15.2 msec. In the majority of patients, the MIPIACT was > 10 msec, and even reached 90 msec in one patient. MIPIACT was longer in patients with a PIACT exceeding 110 msec (P < 0.004). Based on IACT alone, the AV interval must be lengthened on average by 50 msec when changing from atrial tracking‐ventricular pacing to atrial pacing‐ventricular pacing, but large individual differences must be kept in mind. Elderly people should probably have a longer AV delay.

Prognostic value of homocysteinemia in patients with congestive heart failure.

Abstract Background: Elevated plasma homocysteine levels are associated with increased risk of vascular disease and of congestive heart failure (CHF), with a relationship between homocysteine values and disease severity. Hyperhomocysteinemia is a risk factor for cardiac dysfunction. In this study, the predictive value of elevated homocysteine levels was investigated in the prognosis of ischemic and non-ischemic CHF. Methods: A total of 159 patients with CHF, 89 with non-ischemic and 70 with ischemic CHF (83% males, mean age 62years, mean ejection fraction 27%), and 119 controls (79% males, mean age 59.8years) had fasting blood samples taken to measure plasma homocysteine, vitamin B12 and folate levels. Coronary angiography was performed for all patients. The mean duration of follow-up was 49.6±36.7months. Results: As in other studies, the mean level of homocysteinemia was significantly higher in the CHF group (15.80μmol/L) than in the control group (10.90μmol/L) (p=0.001) whatever the etiology (non-ischemic, 16.11±6.84μmol/L; ischemic, 15.41±6.45μmol/L). This result was observed without vitamin deficiency, but in patients, the mean creatinine value was moderately higher than in controls. We found a positive correlation between plasma homocysteine levels and New York Heart Association (NYHA) classification, creatinine and age. Moreover, hyperhomocysteinemia appears to be a powerful predictive factor of mortality in CHF patients (relative risk of death, 4.23; p=0.0003). In the follow-up of this study, 41.5% of patients with homocysteinemia >17μmol/L died vs. 21.3% of patients with levels <17μmol/L. In multivariate analysis, when homocysteine levels were adjusted for a second parameter (age, NYHA, creatinine, diabetes), the risk of death remained significant after each adjustment. Conclusions: Elevated homocysteine levels observed in CHF patients, whatever the etiology of their heart disease (ischemic or non-ischemic), were correlated with the severity of the disease. Hyperhomocysteinemia appears to be a predictive factor of mortality in CHF patients. Clin Chem Lab Med 2006;44:813–6.

Relationship Between Interatrial Conduction Times and Left Atrial Dimension in Patients Undergoing Atrioventricular Stimulation

Interatrial conduction time (IACT) and left atrial dimension (LAD) were determined in 75 patients (41 males, 34 females, mean age 78.2 ± 7,9 years) undergoing atrioventricular (AV) stimulation. The LAD was measured by M mode echocardiography as the distance between the posterior aortic wall and the posterior left atrial wall. The IACT was determined during a transvenous dual chamber pacemaker implant done under local anesthesia (lidocaine). The spontaneous interatrial conduction time (SIACT) was measured from the intrinsic deflection (ID) of the right atrium recorded in a unipolar mode (unipolar J‐shaped had positioned in the right appendage) to the ID of the left atrium (bipolar esophageal lead, left atrial positive deflection equal to the negative one) during sinus rhythm. The right atrium then was paced at a rate slightly greater than the spontaneous one. The paced interatrial conduction time (PIACT) was measured from the stimulus artifact to the left atrial ID. The PIACT was also measured during incremental right atrial pacing (10 beats/min step increase to 180 beats/min) and, from these measurements, the maximum increase of PIACT (MIPIACT) was deduced. The LAD was measured at 39.5 ± 8.7 mm, SIACT at 70.3 ± 24.8 msec, PIACT at 118.8 ± 27.9 msec, and MIPIACT at 16.5 ± 16.4 msec. We found highly significant relationships between SIACT and LAD(P = 0.0006, r ‐ 0.39), PIACT and LAD (P = 0.0001, r = 0.45), and MIPIACT and LAD (P = 0.0006, r = 0.38). We also noted that the LAD was greater in patients in whom MIPIACT was >10 msec than in patients in whom the MIPIACT was negligible (P < 0.002). However, the “r” values indicate that IACT is probably determined by multiple factors, and LAD appears to be one of the most important. Thus, we demonstrated the existence of highly significant relationships between the LAD determined by M mode echocardiography and the IACT when sensing and pacing the right atrium. We also demonstrated that the LAD was greater in patients in whom PIACT increased by an appreciable duration during fast atrial pacing. These results must be kept in mind when choosing a mode of stimulation and determining the AV delay (dual chamber pacemaker), particularly in patients with left atrial enlargement in whom the contribution of the atrial contraction and its timing are hemodynamically determinant.

Cholesterol Embolization Unrecognized Complication of Thrombolysis

A 62-year-old man was admitted to the hospital because of myocardial infarction. Treatment with 100 mg of recombinant tissue plasminogen activator was given intravenously for 90 minutes. On the second day, he presented abdominal and lower limb pain. Physical examination showed a toe and leg livedo …

Usefulness of endocoronary electrocardiogram in the detection of myocardial viability and comparison with single-photon emission computed tomography TI-201

In 20 patients who had recently had an acute myocardial infarction, we compared endocoronary electrocardiographic modifications recorded during angioplasty with thallium-201 for the detection of myocardial viability. Our data demonstrate that endocoronary electrocardiography can be an easy and reliable tool to assess viability, with sensitivity, specificity, and positive and negative predictive values of 100%, 80%, 94%, 100%, respectively.

Correlations of left ventricular diastolic parameters and heart rate: assessment through right ventricular pacing

This study evaluated the correlations between left ventricular (LV) diastolic parameters assessed by equilibrium radionuclide angiography (ERNA) and heart rate (HR) through right ventricular pacing. Twelve patients with a permanent right ventricular apex pacemaker were included. Serial ERNA studies were performed under 6 sets of pacing cycle length (heart rate=52, 62, 72, 82, 92, 104 beats/min) for each patient. The left ventricular ejection fraction was 49.9%±3.1 under pacing HR of 52 bpm and 43.8 %±3.1 % under pacing HR of 104 bpm. The peak filling rate (PFR) increased very significantly with HR (r=0.98, P < 0.001). When the relative changes of end-diastolic volume were taken into account, the correlation between PFR and HR remained significant (r=0.94, P <0.001). The absolute time to PFR (TPFR) did not significantly change with HR, but the ratio of TPFR to cycle length strongly correlated with HR. Our study clearly demonstrates that the PFR assessed by ERNA increases and the TPFR occupies an increasing proportion of the cycle length as HR increases. Therefore, LV diastolic parameters should be normalized for HR in clinical applications. In particular, HR changes should be considered when LV diastolic parameters are used for the assessment of therapeutic interventions.

Accessory Mitral Tissue in a Young Girl

This picture was obtained in a 14-year-old girl referred for a systolic murmur. The patient was asymptomatic. The ECG was normal. Transthoracic echocardiography visualized, in the …