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The detection of coronary disease before valve surgery remains difficult in the absence of coronary arteriography. The contribution of myocardial scintigraphy with dipyridamole (MS-DP) was studied in 34 consecutive patients with valve disease (11 mitral and 23 aortic) with a mean age of 63 +/- 11 years having undergone coronary arteriography before valve surgery. Coronary arteriography was performed because of angina (21 cases) or age (women greater than 50, men greater than 40). Positive criteria of coronary disease were the presence of at least one frank and clearly visible fault of myocardial perfusion (MS-DP positive) and at least one stenosis of greater than 70 per cent by coronary arteriography. Coronary disease existed in 13 patients (38 per cent). Ten patients (29 per cent) had a positive MS-DP. The sensitivity and specificity of MS-DP in detecting coronary disease were 69 per cent and 95 per cent respectively. Its positive predictive value was 90 per cent. MS-DP was negative in all asymptomatic patients (19 per cent of them having coronary disease) and in 11 symptomatic patients (18 per cent of them having coronary disease). The low positive predictive value of angina (52 per cent) increased to 90 per cent when combined with a positive MS-DP. Because of relatively low sensitivity, basing indications for coronary arteriography before valve surgery on the results of MS-DP cannot be advised.

Correlations between left ventricular segmental kinetics and collateral circulation patterns were studied in 292 patients with coronary disease (182 women, 274 men: mean age 54 years). Left ventricular segmental kinetics were analyzed qualitatively by angiography (10 segments were individualized on RAO and LAO projections) and rated as normal, hypokinetic, akinetic or aneurysmal. The type of collateral circulation observed (contralateral, homocoronary and homolateral) and the number of collateral vessels were recorded. Collateral circulation was present in 49 p. 100 of the patients and in 29 p. 100 of the 587 pathological arteries (i.e. more than 50 p. 100 stenosis) identified. 89 p. 100 of the occluded arteries were revascularized by collateral circulation, the latter being effected by 213 collateral vessels (mean: 1.41 +/- 0.36 vessel per occluded artery). Collateral circulation through 1, 2 or 3 collateral vessels was noted in 62 p. 100, 35 p. 100 and 3 p. 100 respectively of the cases. Collateral circulation was contralateral in 51 p. 100, homocoronary in 33 p. 100 and homolateral in 16 p. 100 of the cases. Normal or hypokinetic segments in the territory of an occluded artery were more frequent in the presence (43 p. 100) than in the absence (31 p. 100) of collateral circulation, but the difference was not significant. They were also more frequent in three-vessel patients (59 p. 100) than in one-vessel (21 p. 100; p less than 0.01) or two-vessel (37 p. 100; p less than 0.05) patients in the presence of collateral circulation.(ABSTRACT TRUNCATED AT 250 WORDS)

A new case of late fracture of an outlet strut in a convexo-concave Björk-Shiley valve is reported. The fracture occurred 6 years after aortic implantation of the valve and was responsible for aorto-iliac embolization by the prosthetic disc and death of the patient from cardiogenic shock. This not uncommon complication of the Björk-Shiley valve prosthesis is usually ascribed to the relative fragility of its outlet strut welded to the metallic ring and subjected to strong pressures. Although most cases were observed within the first two years of prosthetic valve insertion, and mainly with valves manufactured in 1981 and 1982, our case and a few others demonstrate the possibility of late rupture. Cardiologists must be aware of this possible complication, since in some favourable cases it can be diagnosed at an early stage and the patient's life can be saved by an emergency operation.

Voluntary sequential ambulatory recording is a diagnostic method of recording per-critical electrocardiographs in symptomatic patients with the aid of a portable solid-state technology recorder. In order to assess the value of this technique in the detection of arrhythmias, a multicenter study was performed in 1,287 symptomatic patients suspected of having paroxysmal arrhythmias (palpitations in 86.5% of cases). The quality of the sequential ambulatory recording was judged to be good in 54.9% and mediocre in 40.2% of cases: only 4.9% of recordings were uninterpretable. This technique allowed identification of a cardiac arrhythmia related to symptoms in 42.5% of the 1,091 cases which were analysed; sustained supraventricular tachycardia (11.7%), ventricular extrasystoles (14.9%) and simple sinus tachycardia (9.5%) were the principal abnormalities. The per-critical recording was negative in 57.5% of patients, suggesting a purely functional origin of symptoms in these cases. Atrial fibrillation was more common in hypertensive patients (11.3% vs 5.5% in normotensives, p less than 0.01) as were ventricular extrasystoles (23.1% vs 13% in normotensives, p less than 0.001). Voluntary sequential ambulatory recording seems to be a technique well adapted to the detection of symptomatic arrhythmias and a useful complement to Holter recording.

The present interest in myocardial contrast echocardiography is related to the development of new contrast agents which can be used intravenously and the perfection of new echocardiographic technologies. Amongst the potential applications of this technique, the study of myocardial perfusion in the acute phase of myocardial infarction is one of the most promising as shown by the experience acquired over several years with intracoronary contrast echocardiography. It allows assessment of the extent of the zones at risk before recanalisation, the presence of collateral vessels and, above all, the quality of myocardial reperfusion. The demonstration of the absence of effective reperfusion of the myocardial microcirculation, or the phenomenon of no-reflow, is one of the main advantages of contrast echocardiography and has been identified as an important independent prognostic factor. This technique could therefore become essential in the evaluation of methods for reducing the extent of microvascular damage. Although many questions remain unanswered about the ideal methods of performing and analysing intravenous contrast echocardiography, the preliminary results confirm the potential of the technique in non-invasive evaluation of myocardial reperfusion in the acute phase of myocardial infarction.

Vascular damage during intervertebral disc surgery is uncommon. It sometimes leads to the formation of an arteriovenous fistula and about one hundred cases have been reported in the literature. The diagnosis is often early, with signs of venous hypertension predominating. The authors report a case of arteriovenous fistula presenting late as apparently primary congestive cardiac failure. The mechanisms of this condition were demonstrated during preoperative instrumental manoeuvres. Surgical correction is the only treatment alternative. Repair must be arterial and venous, most often using prosthetic material. This generally enables total and permanent recovery, but overall mortality in pathology of this type is not nil.

The authors report the case of a right ventricular metastasis presenting with ventricular tachycardia and underline the usual diagnostic problems of secondary cardiac tumours, the symptoms of which are often unspecific and late. The appearance of a cardiac arrhythmia in the absence of known cardiac disease should raise the possibility of a cardiac metastasis in patients with malignant disease. The reported case also illustrates the diagnostic value of non-invasive cardiac imaging techniques (echocardiography and ultra-fast computerised tomography) in this context.

201TI reverse redistribution is a common finding early after reperfusion therapy for myocardial infarction. Its mechanism and clinical implications remain unclear. The aim of this study was to clarify the relationships between reverse redistribution, microvascular perfusion, and myocardial viability.Resting, 10-min-postinjection, and redistribution 201TI data obtained for 33 patients 8 and 42 d after the onset of acute myocardial infarction were compared with echocardiographic wall motion measured acutely and on day 42. Microvascular perfusion was assessed by myocardial contrast echocardiography performed 10 min after restoration of complete patency of the infarct artery.Marked significant reverse redistribution was found on day 8 (absolute change, 7.5%+/-7.9% of the 10-min-postinjection defect size; P5x0.000001) and significantly decreased on day 42 (2.7%+/-6.8%; P = 0.004 between days 8 and 42). The 10-min-postinjection defect size best predicted the final infarct size on day 42 and was closely related to microvascular perfusion. Patients with adequate reperfusion had a smaller postinjection defect on day 8 (21.1%+/-14.6%) and a larger reverse redistribution (10.2%+/-6.1%) than did patients with no reflow (35.3%+/-13% and 3.2%+/-9.2%, respectively; P0.04 for both).Reverse redistribution was marked early after myocardial infarction in patients with complete patency of the infarct artery and decreased in subsequent weeks. Reverse redistribution was associated with restoration of adequate microvascular reperfusion and with myocardial salvage and viability. The early postinjection scans on day 8 were the relevant images for assessing myocardial salvage and predicting wall motion recovery.