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Purpose: To develop profile of the victims and to study circumstances, causes of death and autopsy findings., Methods: Retrospective study of cases of sudden death in sport activity whose autopsy was performed in forensic department of Tunis, between January 2005 and December 2009., Results: During study period, 32 cases of SD in sport activity were recorded. These are amateur athletes predominantly male (84% of cases). Victims are aged between 15 and 79 years with an average age of about 33.16 years. Young subjects whose age is less than 35 years representing 68.7% of cases. 9.3% of victims had a family history of SD and 18.7% of cases had a known cardiac history. The sports most involved are running (40.6% of cases), football (31.3% of cases) and dance (12.5% of cases). Sixty-nine percent of victims died during sports activities. Presence of witnesses was noted in all cases; however, none of these witnesses has begun resuscitation. Cause of death was cardiac in 84.4% of cases. In young athletes, hypertrophic cardiomyopathy is the leading cause (nine cases), followed by arrhythmogenic right ventricular dysplasia (three cases). Among other causes, there is the myocardial bridge, congenital anomalies of the coronary arteries, aortic dissection and dilated cardiomyopathy. Beyond 35 years, coronary artery diseases represent the cause of death (nine cases). Only case of death secondary to non-cardiac disease occurred after a severe asthma attack. In four cases (12.5%), no cause of death was identified after a complete autopsy accompanied by further investigations. The cause of the death was imputed to a rhythmic pathology., Conclusion: This is the first study dealing with autopsy in SD in sport have provided a specific profile of victims. Other studies on larger samples and using standardized autopsy protocols are needed., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

The use of levosimendan (Simdax(®)) was described in cases of acute cardiac failure in patients with peripartum cardiopmyopathy. We report the case of a 36 years old Philippine woman with an undiagnosed dilated myocardiopathy. She developed an acute severe left ventricular dysfunction in the early postpartum period after a cesarean section, possibly related to the recurrence of an unknown peripartum myocardiopathy. Due to failure of the conventional treatment with diuretics and inotropic support, an intra-aortic balloon with counter-pulsation was inserted. In rescue, treatment with levosimendan permitted to wean the patient from haemodynamic support, and a heart transplant was probably avoided. Three months later, a new echocardiography showed a persistent left ventricular dilation and a still marked alteration of left ventricular ejection fraction (28%)., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Unlabelled: The aims of this work are to study the nursery futures during idiopathic myocardiopathy of peripartum (IMPP), to measure the prevalence of thromboses and spontaneous contrast during the IMPP and to determine their evolution., Methodology: It is about a longitudinal exploratory study carried out with the Aristide-Le-Dantec teaching hospital of Dakar, beginning January 2001 to November 2004, having included 33 patients., Results: The average age of the patients was 26 years; the average pregnancy was of 3.39 gestures. The signs of cardiac insufficiency were constant and four patients (12%) had presented an ischemic cerebral vascular accident. We had raised an auricular case of fibrillation and tachycardia atrial multifocal. The transthoracic echography (ETT) noted an aspect of hypokinetic myocardiopathy dilated with deterioration of the systolic function of the left ventricle, a thrombus in ten patients (30.3%) and a spontaneous contrast in two cases (6%). The transoesophageal echocardiography (ETO) was superposable with the ETT with regard to dimensions of the cardiac cavities and the presence of thrombus but its sensitivity was higher (100% against 66%) with regard to the detection of contrasts spontaneous. All the patients had the treatment of a congestive heart failure associated to an anticoagulant treatment. The evolution was marked by an improvement of the heart failure. The thrombus and spontaneous contrast had disappeared in all the patients. The absence of anaemia and the presence of spontaneous contrast (p=0.003) were correlated with the presence of thrombosis (p=0.05)., Conclusion: The idiopathic myocardiopathy of the peripartum is a relatively frequent affection in zone Soudano-Sahelian. Occurrence of thromboses is frequent at the time of this affection. Our study confirms the superiority of the echocardiography transoesophageal in the detection of intracardiac spontaneous contrast. The evolution can be favourable subject to a rigorous care and a regular surveillance., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Multiple mechanisms can explain a tachycardia associated or not with a heart disease. It is important to establish its origin, particularly if advanced heart disease is present, for the treatment. Complete electrophysiological study remains an important means of diagnosis. We report the case of a 39-year old man, who had a dilated cardiomyopathy since the age of 25 years and who complained of tachycardia. These symptoms were shown to be related to atrioventricular nodal re-entrant tachycardia at electrophysiological study and a specific treatment was indicated.

Electrical storm in patients with implantable cardioverter defibrillator (ICDs) is a rhythmic emergency which can be immediately lethal. It occurs especially in patients with an advanced cardiomyopathy. Such arrhythmias predictor factors and triggers are rarely found. We report the case of a 73-year-old man with ischemic dilated cardiomyopathy, who underwent a complete surgical revascularisation six years ago. In 2003, this patient was hospitalised in cardiology because of a sustained ventricular tachycardia reduced by electrical shock. Because of the aggravation of the heart failure with a NYHA functional class III, electrical and echocardiographic criteria of ventricular dyssynchrony, a biventricular ICD was implanted. Three years after, the patient was hospitalized because of an electrical storm with 96 appropriate shocks. A severe hypokaliemia was the cause of this electrical storm, and the evolution was favourable after correction of the hypokaliemia. Hypokaliemia is rarely the trigger of such arrhythmias, it represents only 3 % of the causes. Its prevalence may be underestimated especially in patients with heart failure who receive high doses of diuretics., (Copyright (c) 2009. Published by Elsevier SAS.)

Massive bleeding is a dreaded complication of biventricular mechanical assistance implantation. Its origin is multifactorial. Blood products transfusion associated with correction of coagulopathy are sometimes insufficient. We report two cases of massive bleeding after a Thoratec biventricular assistance implantation. After surgical haemostasis failure and despite the correction of coagulation disorders, a major bleeding persisted, so these patients received a single injection of 90 microg/kg of rFVIIa. This allowed in both cases a significant reduction of the bleeding and the restoration of normal haemodynamic conditions. This treatment was not complicated by any thrombotic accident., (Copyright 2009. Published by Elsevier SAS.)

Malignant glucagonoma is an exceptional pancreatic endocrine tumour, with frequent dermatologic symptoms, diabetes and degradation of the general health status. Prognosis is unfavourable when liver metastases are present due to the usual inefficiency of chemotherapy. We report here an observation of a patient who was treated for a glucagonoma with multiple liver metastases, migratory necrolytic erythema, dilated cardiomypathy and diabetes that dramatically improved after a dacarbazin-based chemotherapy, allowing subsequent surgical resection of the primary. The patient was still alive and asymptomatic without progressive disease nearly two years after surgery., (Copyright 2009. Published by Elsevier Masson SAS.)

Purpose: Peripartum cardiac failure is common in savannah-Sahelian Africa. It is due to a form of dilated cardiomyopathy (DCM) known as peripartum cardiomyopathy (PPCM) that results from undetermined causes. Numerous risk factors have been identified and dietary selenium deficiency has been proposed as a possibility. The purpose of this study was to measure serum selenium levels in patients presenting cardiac insufficiency due to PPCM and DCM (nonpostpartum) in Cotonou, Benin and to compare patients with healthy postpartum women with comparable or identical obstetric features., Methods: Measurements of selenium status were performed in 10 women (mean age, 27.1 years) with PPCM, 18 patients of both sexes (male/female, 11/7; mean age, 38.9 years) with DCM (non-peripartum), and 46 healthy recent post partum women (mean age, 29.8 years). The Wilcoxon nonparametric test was used for data analysis with a statistical significance level at a p-value <0.05., Results: Mean serum selenium values were near similar in patients presenting PPCM and DCM (non peripartum): 94 +/- 12 microg/L versus 97 +/- 19 microg/L respectively. This difference was not significant. No value was less than 72 microg/L. Conversely significantly lower mean values were observed in the 46 healthy recent postpartum women: 76 +/- 13 microg/L (p = 0.0002). The lowest value was 57 microg/L., Conclusion: Serum selenium measurements in Cotonou showed that levels were higher in patients presenting PPCM or DCM (nonperipartum) than in healthy controls. Extremely low values were never observed. These results differed from those obtained in Bamako, Mali and in Niamey, Niger and argue against considering selenium deficiency as a risk factor for development of DCM (peripartum or not) in Cotonou.

The benefit of implantable cardioverter defibrillators (ICD) on total mortality has been demonstrated in primary prevention for heart failure patients, in whom they improve clinical outcomes. However, some of these patients present incessant ventricular tachycardia and receive appropriated shocks and antitachycardia therapy. Radiofrequency catheter ablation is an efficacious method to prevent the occurrence of stable ventricular tachy-arrythmia. We present here, the case of a patient with dilated cardiomyopathy implanted with an ICD in secondary prevention (ventricular tachycardia [VT]). The ICD delivered multiple appropriated shocks for monomorphic VT. A radiofrequency catheter ablation was successfully performed and the patient receives no further shock for the whole 18 months follow-up.

Introduction: Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease of unknown aetiology. The primary objective of this review was to analysed aetiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis of this pathology., Methods: We undertook a systematic review of the literature using Medline, Google Scholar and PubMed searches., Results: Unlike other parts of the world in which cardiomyopathy are rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Its aetiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. This diagnosis should be limited to previously healthy women who present with congestive heart failure (CHF) and decreased left ventricular systolic function in the last month of pregnancy or within 5 months after delivery. Recently, introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Conventional treatment consists of diuretics, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. Patients who fail to recover may require inotropic therapy. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover normal heart function., Conclusion: PPCM is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Its aetiopathogenesis is still poorly understood. Introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Prognosis is highly related to reversal of ventricular dysfunction.

Introduction: The physiopathology of visual hallucinations in the hemianopic field secondary to occipital infarct is uncertain., Case Report: We report the case of a patient with a history of occipital infarct who presented nonstereotyped complex hallucinations in the quadranopic field resulting from a second controlateral occipital infarct. Based on an experience with motion optical illusions, we suggested that the association of these two occipital lesions, involving the V5 motion area on the one side and the V1 area on the other side, could have produced the complex hallucinations due to a release phenomenon. The patient experienced simultaneously a double visual consciousness, with both hallucinations and real visual perceptions., Conclusion: The study of perceptual illusions in patients with visual hallucinations could illustrate the innovative theory of visual consciousness as being not unified but constituted of multiple microconsciousnesses.

We report a case of a 55-year-old woman who has a non-compaction of the left ventricular myocardium diagnosed after a cardiac arrest due to a polymorphic ventricular tachycardia. The patient was implanted with a cardioverter-defibrillator. A review of literature of this recently described cardiopathy is done.

The authors report a case of cardiomyopathy of the right ventricle revealed suddenly in a presentation of pulmonary embolism in relation to a large thrombus that developed in an enormous, extremely hypokinetic right ventricle. The scenario suggests dysplasia without rhythm disorder. This case allows a discussion on the multiple variants of arhythmogenic dysplasia of the right ventricle.

Syncope occurring in patients with primary dilated cardiac disease has several causes: ventricular tachycardia (VT), a major severe cause of this diagnosis, occurring however only in one third of cases. The other causes are supraventricular tachycardia, bradycardia and vagal hyperactivity. The management depends on the etiology of syncope in one hand and the severity of the cardiac disease and other comorbidities in the other hand. In 2007, a patient with life expectancy exceeding one year, without irreducible heart failure but with a known and stable altered left ventricular ejection fraction (LVEF)<30%, will probably benefit of non-drug technology for the treatment of syncope (defibrillator with or without resynchronization), possibly in association with the treatment of another identified etiology, such as ablation or anti-arrhythmic treatment of a supraventricular tachycardia. In a patient with LVEF>30%, the electrophysiology exploration remains the most reliable recommended investigation for identifying the cause of syncope prior to discuss the implantation of a portable Holter device, indicated when the electrophysiology study is negative and syncope repeating.

Unlabelled: The significance of atrial fibrillation (AF) in idiopathic dilated cardiomyopathy (IDCM) remains discussed. The purpose of the study was to evaluate the clinical significance of permanent atrial fibrillation in patients with IDCM., Methods: Systematic noninvasive and invasive studies including Holter monitoring, measurement of left ventricular ejection fraction (LVEF), electrophysiological study and coronary angiography were performed in 323 patients with IDCM; all patients had a left ventricular ejection fraction (LVEF)<40%. The studies were indicated for spontaneous ventricular tachycardia (VT) in 69 patients, syncope in 103 patients and nonsustained VT on Holter monitoring in 151 asymptomatic patients. Sixty-five patients were in permanent AF (group I). Remaining patients were in sinus rhythm at the time of evaluation (group II). Programmed ventricular stimulation using up to 3 extrastimuli in control state and if necessary after isoproterenol was systematic. Patients were followed 3+/-2 years., Results: Mean age was significantly older in group I (61+/-8 years) than in group II (52+/-12) (P<0.01). Syncope (31 vs 36%), spontaneous sustained VT (18 vs 23%); mean LVEF (28+/-9% vs 29+/-9%), VT induction (25 vs 35%) were similar in both groups. During the follow-up, there were no statistical differences between groups I and II concerning each event: sudden death occurred in 13 patients, 1.5% of group I patients and 5% of group II patients (NS); a death related to heart failure occurred 22 patients, 5% of group I patients and 7% of group II patients (NS); heart transplantation was performed in 13 patients, 8% of group I patients and 3% of group II patients (NS)., Conclusions: An older age is the only significant clinical factor associated with the presence of a permanent atrial fibrillation in idiopathic dilated cardiomyopathy. The presence of permanent AF does not increase the induction of a sustained ventricular tachycardia and does not affect the general prognosis of IDCM.

Aim: To analyze the clinical characteristics and to evaluate the different factors that influences the prognosis of the peripartum cardiomyopathy (PPCM)., Methods: A retrospective review was undertaken on records of women who were diagnosed with peripartum cardiomyopathy at Farhat Hached Hospital (Sousse) between January 1992 and December 2004., Results: Clinically, PPCM shows pulmonary symptoms such as dyspnea and tachypnea. The diagnosis is established by echocardiography that showed decreased systolic function of the left ventricular. Both gynecologist and cardiologist must check the patients regularly. No patient died. Three preterm pregnancies occured with 9 health newborns (2 sets of twins). One miscarriage took place. PPCM is often undetected or misdiagnosed because of the low incidence and the unspecific symptoms. The treatment is also unspecific and similar to dilated cardiomyopathy or acute cardiac failure., Conclusion: Early diagnosis of the peripartum cardiomyopathy is extremely important. Pregnancy in patients with dilated cardiomyopathy is associated with maternal and fetal morbidity. Left ventricular function is a prognostic factor and must be the most parameter when conseling patients with peripartum cardiomyopathy about a new pregnancy.

The authors present the case of a patient who developed left bundle branch block with asynchrony of left ventricular contraction and, secondarily, a dilated hypokinetic cardiomyopathy. There were no signs of an ischaemic, toxic or inflammatory cause for the cardiomyopathy whereas cardiac resynchronisation by biventricular stimulation rapidly restored a normal left ventricular ejection fraction. This suggests that asynchrony of left ventricular contraction is not necessarily the consequence of a dilated hypokinetic cardiomyopathy but it may also be considered as a possible cause.

A case of dilated ischemic cardiomyopathy, with severely impaired left ventricular systolic function, treated by endoventriculoplasty and CABG, is reported. The authors discuss the modern concepts regarding the surgical treatment of large anterior asynergic scars following occlusion of the LAD. Since there are more similarities between akinesia and dyskinesia than previously thought, the endoventriculoplasty of DOR may constitute a new way to surgically remodel the left ventricle in dilated cardiomyopathies with large anterior akinesia. This surgery significantly improves the ventricular function and the overall patients' prognosis at short and mid term follow up.

Here we report 2 cases of hypocalcemic cardiomyopathy revealing a 22q11 microdeletion syndrome. This presentation at diagnosis is rare as the cardiac phenotype is mainly made of conotruncal congenital heart defects in this condition. Cardiac failure was diagnosed during the neonatal period in the 2 cases and was associated with profound hypocalcemia. As usual, treatment with calcium and vitamin D led to the regression of the hypocalcemia and the left ventricular function was fully restored. While this circumstances are unusual, we recommend that screening for 22q11 deletion should be performed when confronted to hypocalcemic cardiomyopathy or left ventricular systolic dysfunction in conotruncal defects in neonates.

Rituximab (Mabthera) is used in the treatment of refractory low-grade non-Hodgkin's lymphoma or in case of relapse after chemotherapy. Among the different adverse reactions with this drug, the most common is a constellation of symptoms (fever, rigors and chills) that occur more frequently during administration of the first dose of drug. These symptoms could be related to a cytokine-release syndrome. We report the case of a 46 year-old patient, presenting a familial cardiomyopathy, deceased a few minutes after having developed this syndrome, at the time of the 2nd infusion of rituximab. Several hypothesis have been suggested to explain this sudden death: a cardiac failure following deterioration of the systolic function, potentially related to the negative inotropic effects of TNFalpha, and/or an impairment of the diastolic function following the volemic overload. The impact of the reflex "administration of monoclonal antibody/cytokine-release syndrome" was only little investigated under physiologic or pathologic conditions. In spite of a risk of adverse reactions apparently moderated compared to the other drugs used in this context, this case report underlines the need for a special attention when using rituximab among patients with cardiac risk factors (reassessment of the benefit-risk ratio, specific monitoring, pre medication). More generally, it underlines the need for a systematic and continuous identification and reporting of adverse drug reactions to the French network of regional pharmacovigilance centres.

The causes of adverse prognosis of patients with primary dilated cardiomyopathy remain controversial. Classically, it is thought that syncope is associated with an increased risk of mortality. The aim of this study was to try and identify the causes and prognostic significance of syncope in patients with primary dilated cardiomyopathy. Sixty-five patients aged 31 to 80 with primary dilated cardiomyopathy were admitted for investigation of syncope. The average ejection fraction was 27 +/- 10%. Invasive and non-invasive investigations including complete electrophysiological investigations, were performed. Sustained monomorphic ventricular tachycardia was induced in 14 patients (21.5%), ventricular flutter or fibrillation was induced in 9 patients (14%), a supraventricular arrhythmia in 17 patients (26%), and a conduction defect alone or associated with another arrhythmia in 7 patients (11%). A pathological result of tilt testing was observed in 5 patients (8%). No cause of syncope could be demonstrated in 15 patients (23%). During follow-up (4 +/- 2 years) there was a mortality of 15% which was only correlated with the reduction in left ventricular ejection fraction. The authors conclude that there are many causes of syncope in primary dilated cardiomyopathy: ventricular arrhythmias represent only 35% of cases and do not impact on the prognosis; above all, left ventricular ejection fraction is the most important prognostic factor.

Radiofrequency ablation of ventricular tachycardia in cardiopathy essentially concerns the post-infarct period, but also dilated cardiopathy and arrhythmogenic right ventricular dysplasia. This technique relies greatly on the new computer assisted mapping techniques and intracardiac navigation. The mechanism is usually a macro-reentry which is formed on contact with a scarred, fibrous or dysplastic area. The activation site has a figure of eight appearance with a slow conduction zone activated in diastole and surrounded by areas of anatomical or functional block. This protected isthmus can be confirmed with exercising manoeuvres. Failing that, it can be identified by indirect criteria, notably when the tachycardia is not triggered or not tolerated haemodynamically. The success rates are higher in trained centres, and the morbidity/mortality of such procedures are low. Ablation is aimed at continuous or frequent tachycardias in order to limit interventions in patients fitted with an implanted defibrillator. Radiofrequency ablation in the case of idiopathic ventricular tachycardia is different because it is relatively easy when there is a right infundibular origin or a fascicular ventricular tachycardia, which is usually derived from the left posterior hemibranch conduction tissue. The situation is more delicate in the case of atypical localisation. Faced with this type of symptomatic tachyacardia, ablation is a fall-back method after failure of medical treatment.

Dilated cardiomyopathy (DCM) of genetic origin represents about 25% of all so-called primary DCM. Cases due to mutation of the gene which codes the lamins A and C (LMNA) carry a poor prognosis with a high risk of sudden death. The finding of primary DCM in a young person associated with conduction defects or arrhythmias should lead to investigation for mutation of the gene of lamins A and C, even in the absence of a suggestive family history. The authors report 5 cases of DCM, with and without associated skeletal muscular disease, due to laminopathies.

Implantable cardioverter-defibrillator has been used in the primary prevention of sudden cardiac death. We review its indications according to the underlying cardiac disease based on the recommendations of the scientific societies. We briefly discuss the new problem of its utilization in patients with severe heart failure.

Unlabelled: We analysing 8 cases of diabetes secondary to primary hemochromatosis in a group of black diabetic patients in Yaoundé. Diagnosis of primary hemochromatosis is based on clinical and biological arguments. Central hypogonadism is associated to diabetes in 75%, dilated cardiomyopathy existed in 37.5%, arthropathy in 75%. Diabetes is mostly type II., Conclusion: Secondary diabetes to primary hemochromatosis does exist in Black Africa. Diagnosis should be in the mind of clinician when in a diabetic patients are associated: central hypogonadism, dilated cardiomyopathy and chronic arthropathy. In the future diagnosis of hemochromatosis will be easier by genetic because of recent discovery of the gene of the disease.

Behçet's disease is associated with cardiac complications which may affect all three cardiac layers in 1 to 6% of cases. Although pericardial and coronary disease are the most common, the myocardium may also be affected. The clinical presentation may be left ventricular dysfunction with signs of dilated cardiomyopathy. The cause of the left ventricular dysfunction is usually coronary artery disease but it can also be inflammatory, resulting in a myocarditis with normal coronary arteries. The authors report two cases of Behçet's disease with symptomatic left ventricular dysfunction presenting as dilated cardiomyopathy with normal coronary arteries in one of the cases. Recent echocardiographic studies suggest that the incidence of myocardial disease is underestimated in this pathology: 20 to 35% of patients with Behçet's disease but no cardiac symptoms had left ventricular diastolic dysfunction. A more attentive investigation of left ventricular diastolic function in these patients should enable earlier diagnosis of this complication.

A caesarean section was indicated in a 29-year-old parturient affected by a muscular deficit in myophosphorylase responsible for a type V glycogen storage disease (McArdle disease). This metabolic myopathy had been diagnosed two years previously, whereas the patient already suffered from a hereditary form of dilated cardiomyopathy. The muscular disease was invalidating on the functional level with exercise intolerance. The cardiopathy was little symptomatic but the dysfunction of the left ventricle worsened during the pregnancy with an ejection fraction calculated to 43%. In this case, we report the realization of a general anaesthesia in a patient who had epidural anaesthesia for a previous caesarean section.

A revue of litérature about peripartum cardiomyopathy; a disease of unknown pathogenesis. Some retrospective studies suggest a relation with sexually transmitted diseases. Other risk factors were observed. Diuretics and digoxin are used in the treatment. Cardiac transplantation is the final solution but the affection could appear again. A database must be started with epidemiologic information to understand this disorder and its correlation with sexually transmitted diseases.

A 26-year-old woman developed congestive heart failure (CHF) secondary to idiopathic dilated cardiomyopathy. Despite aggressive pharmacological therapy, her disease progressed over the next year, causing massive edema and dyspnea at rest. Although a sleep study showed no clinically significant sleep apnea, she was treated with nocturnal continuous positive airway pressure (CPAP). Following application of CPAP, a remarkable improvement in her condition was observed, with resolution of her edema and alleviation of dyspnea. Left ventricular ejection fraction increased from 29% to 43% and left ventricular dimensions decreased. Previous studies have demonstrated that nocturnal CPAP exerts a number of favourable effects on cardiovascular function in patients with CHF who suffer from a coexisting sleep apnea disorder. This report illustrates that CPAP can also have beneficial long term effects on the failing heart even in the absence of clinically significant sleep apnea.

Angiotensin converting enzyme (ACE) inhibitors are associated with a greater reduction in mortality in non-ischaemic cardiomyopathy than in ischaemic cardiomyopathy after the results of the V-HeFT-II and SOLVD trials in symptomatic patients. However, a recent analysis of the global, symptomatic and therapeutic, results of the SOLVD trials, demonstrated a similar reduction in mortality with ACE inhibitors in ischaemic and non-ischaemic cardiomyopathies. Moreover, after myocardial infarction, the beneficial effects of ACE inhibitors have been well established in patients with left ventricular dysfunction. Betablockers, especially bisoprolol in the CIBIS-I trial, also seem to be more effective in non-ischaemic cardiomyopathy. However, CIBIS-II and the US Carvedilol Heart Failure Trial Program clearly showed that the benefits of betablockade were identical whether ischaemic or not. The beneficial effects of betablockers in the post-infarction period are more marked when left ventricular dysfunction is severe. The PROVED and RADIANCE trials suggest that digitalis is more effective in non-ischaemic cardiomyopathy. These results were not confirmed by the DIG trial which showed a significant reduction in the combined criterion, mortality and hospital admission for aggravation of cardiac failure, both in ischaemic and in non-ischaemic cardiomyopathy. However, the use of digitalis should be prudent during ischaemic cardiomyopathy, the neutral effect on global mortality in the DIG trial masking divergent results with a tendency to reducing mortality due to aggravation of cardiac failure and a significant increase of other causes of cardiac death, especially from myocardial infarction and arrhythmias. Amiodarone could also be useful in non-ischaemic cardiomyopathy. The reduction in risk of death in the GESICA study, which comprised 60% of patients with non-ischaemic cardiomyopathy, contrasting with the absence of an effect with this molecule in the STAT-CHF trial which only comprised 29% of patients with non-ischaemic cardiomyopathy. The new generation of calcium antagonists could also be more effective in non-ischaemic cardiomyopathy. Although amlodipine significantly reduced mortality in the PRAISE trial in non-ischaemic cardiomyopathy, there was no favourable effect with felodipine in the V-HeFT-III tria. Finally, if in the earlier studies oral anticoagulants were more effective in non-ischaemic cardiomyopathy, the recent results of the SOLVD trial showed that warfarin decreased the mortality in both ischaemic and non-ischaemic cardiomyopathy. The value of anti-aggregant therapy is not questioned in coronary artery disease, but its role in dilated cardiomyopathy has not yet been established. In conclusion, apart from the use of digitalis which must be prudent in post-infarction cardiomyopathy or in patients with ventricular arrhythmias, the treatment of cardiac failure differs little with respect to its ischaemic or non-ischaemic aetiology, and should be based on the NYHA (New York Heart Association) classification.

Analysis of heart rate variability is an attractive, non-invasive method for studying the cardiac response to stimulation by the autonomic nervous system which is decreased in chronic cardiac failure. The prognostic value of heart rate variability in cardiac failure has been the subject of recent research. The 24-hour standard deviation is the commonest parameter with an independent predictive value for mortality. However, its threshold value is variable according to the different studies. The percentage of successive RR intervals varying by more than 50 ms is a sign of parasympathetic activity and is not found to be an independent prognostic factor by all workers. The results of values of low frequency on spectral analysis are contradictory. Finally, the Poincaré graphic method showing an abnormal graph is one of the only predictive factors of sudden death. Blood pressure variability will probably complete the analysis of heart rate variability as a prognostic factor of chronic heart failure.

The objective of this study was to define the echocardiographic indices predictive of persistence of left ventricular dilatation one year after valve replacement for chronic aortic incompetence. Thirty four consecutive patients (32 men and 2 women, age: 35.6 +/- 10 years) operated for post-rheumatic chronic aortic incompetence, were included in this series. All patients were investigated by echocardiography less than 15 days before and one, six and twelve months after surgery. The parameters studied consisted of measurement of ventricular diameter, shortening fraction and ejection fraction as well as aortic incompetence Doppler indices (jet-left ventriculr outflow tract diameter, jet-left ventricular outflow tract diameter/subaortic diameter ratio, half-pressure time, aortic isthmus end-diastolic velocity). Preoperative echocardiographic data and the results one year after valve replacement were compared for each patient. The left ventricle remained more dilated at one year in patients with a preoperative end-diastolic diameter > 80 mm, an end-systolic diameter > 55 mm, a shortening fraction < 25%, an ejection fraction < 50%, a jet diameter > 16 mm, a jet diameter/subaortic diameter ratio > 65% or a half-pressure time < 350 ms. In conclusion; an end-diastolic diameter > 80 mm, an end-systolic diameter > 55 mm, a shortening fraction < 25%, a jet diameter > 16 mm, a jet diaméter/subaortic diameter ratio > 65% and a half-pressure time < 350 ms appear to represent the main predictive factors of the persistence of ventricular dilatation one year after aortic valve replacement for chronic aortic incompetence.

Background: Left ventricular failure has been described following surgery due to localized compression of the left ventricle and in case of diastolic left ventricular dysfunction after pericardiotomy or pericardiocentesis., Case Reports: Global heart failure was observed in 3 patients with dilated cardiopathy who developed tamponade. Systolic left ventricular dysfunction was caused by ischemic heart disease in one patient and secondary to anthracyclin chemotherapy in the two others. The effusion was successfully removed with pericardiocentesis in all three cases. No specific complications were observed., Discussion: Although exceptional, tamponade may occur in patients with signs of left ventricular failure.

Masquerading bundle branch block associates left bundle branch block in the standard lead and right bundle branch block in the precordial leads. Mr R., 67 year old, was referred for investigation of syncope. He had a history of idiopathic dilated cardiomyopathy (normal coronary arteries; EF: 14%, CI: 2.2 l/min/m2 at later investigations). The ECG showed LBBB with left axis deviation, a PR interval at the upper limits of normal and ventricular premature beats. During observation, he had another syncopal episode and the ECG showed wide complex tachycardia (160 bpm) reduced by external cardioversion. Electrophysiological investigations showed inducible VT due to bundle branch reentry. The HV interval in sinus rhythm was 80 ms. Radiofrequency ablation of the right bundle led to first degree AVB with masquerading bundle branch block with an increased HV interval of 120 ms. The usual facility of ablation of the right bundle branch block is an argument in favour of the hypothesis whereby masquerading bundle branch block is a variety of RBBB with severe conduction defects of the two branches.

The authors undertook a prospective and comparative echocardiographic study of 2.5, 3.5 and 5 MHz ultrasonic transducers for the detection of left ventricular mural thrombosis in 53 patients with left ventricular dysfunction. Thirty-three patients had advanced ischaemic heart disease following anterior myocardial infarction and 20 had dilated cardiomyopathy with a left ventricular ejection fraction of < or = 40%. Eighty-two per cent of patients had anticoagulant therapy. The diagnosis of thrombosis was based on Asinger's classification. Eleven thrombi were detected, an incidence of 21%. Using the 5 MHz transducer as a reference, the sensitivity of the 3.5 MHz transducer was 100% and much greater than that of the 2.5 MHz transducer (55%) which was associated with 4 false positive results. The specificities were respectively 97 and 86% for the 3.5 and 2.5 MHz transducers. There was no correlation between the apical Doppler flow velocities and the presence of mural thrombosis. Atrial fibrillation was significantly associated with mural thrombosis (p = 0.04). The increased sensitivity associated with transducers of higher frequency is, however, limited by the echogenicity of patients. The introduction of transducers of variable frequencies should facilitate the diagnosis and improve the sensitivity of echocardiography in detecting left ventricular mural thrombosis.

Of the three physiopathological types of cardiomyopathy, dilated, hypertrophic and restrictive, it is the first which characteristically shows major left ventricular systolic dysfunction. The left ventricular volumes are increased, the ventricle becomes spherical and global ejection fraction decreases with diffuse or segmental wall motion abnormalities. The left ventricular mass is increased in an excentrical fashion with wall thinning. Isovolumic contraction is slower, the ejection time is shorter and, above all, the indices of contractility such as maximal velocity of the contractile elements ... are very abnormal and do not improve after positive inotropic stimulation.

There are three types of cardiomyopathy: hypertrophic, dilated and restrictive. The diagnosis and prognosis of these three types may be assessed from Doppler echocardiographic data. In hypertrophic cardiomyopathy, the diagnostic criterion is parietal hypertrophy. This hypertrophy is asymmetrical and usually affects the interventricular septum. Ventricular outflow obstruction is not necessarily present. The left ventricle is small and analysis of mitral inflow usually shows abnormal relaxation (E/A ratio < 1). The prognosis of this type of cardiomyopathy seems to be related to ventricular arrhythmias and the relationship between the hypertrophy and the presence of arrhythmias remains controversial. Dilated cardiomyopathy is characterized by ventricular walls of normal or decreased thickness, an increase in left ventricular dimensions and a reduction in the ejection fraction. An end-diastolic left ventricular dimension > 70 mm and an ejection fraction < 25% are poor prognostic factors. Left ventricular filling is abnormal and severe cases show a restrictive type of profile; in this case, an E/A ratio > 2 carries a poor prognostic. A mitral deceleration time of E wave < 150 msec usually indicates a bad outcome. Restrictive types of cardiomyopathy are more rare, amyloidosis being the commonest cause. Symmetrical wall thickening and a small ventricular chamber are observed. In advanced stages with abnormal systolic function, an E/A mitral ratio > 2 and deceleration time < 150 msec, the outcome is rapidly fatal.