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Resume On sait que le vieillissement est accelere par des facteurs de risque. La continuite entre vieillissement normal et vieillissement pathologique est tres discutee. Dans le cadre du vieillissement cerebral, il a paru interessant d'utiliser des techniques statistiques appliquees aux parametres extraits de l'electroencephalogramme (EEG) par l'analyse spectrale. Trois groupes ont ete etudies ici: des sujets normaux indemnes de toute affection neurologique ou cardiaque, des sujets atteints de demence de type Alzheimer et des patients porteurs d'une affection cardiaque n'ayant pas de retentissement cerebral clinique. En utilisant l'analyse discriminante pas a pas, on a montre que les parametres differenciant sujets sains et sujets cardiaques non cerebroleses etaient en effet differents de ceux qui separent les sujets Alzheimer des normaux. De plus, on a pu egalement distinguer les Alzheimer des sujets âges cardiaques.

CARDIAC allograft vasculopathy (CAV), also referred to as “chronic rejection,” remains the leading known cause of death occurring more than 1 year after heart transplantation. The prevalence of CAV, when detected by coronary angiography, is 40% to 50% 5 years posttransplantation. Preventive treatment of CAV with diltiazem was reported in only one study. In contrast, promising results have been published after primary prevention with pravastatine and simvastatine. CAV is a mixture of midand distal vessel narrowing with distal vessel occlusion. In some cases, focal and proximal stenosis may also be involved. These proximal lesions, comparable to native coronary atherosclerotic lesions, may profit by new techniques: balloon angioplasty, whose effectiveness has been well established in native coronary artery disease; and coronary stenting, which has been demonstrated to be useful in cases of incomplete result or local dissection after angioplasty. Moreover, in native atherosclerosis, coronary stenting has been shown to decrease restenosis. In CAV, balloon angioplasty in several published series has demonstrated primary success rates similar to those of native coronary atherosclerosis. However, unusually high restenosis rates (55% at 8 months) were reported in the North American Multicenter Registry. As regards the treatment of CAV with coronary artery stenting, very limited experience has been reported. The present study reports our experience with repeated balloon angioplasty in nine transplant patients systematically followed up at least 6 months by coronary angiography. The interventional procedure consisted of conventional percutaneous transluminal coronary angioplasty (PTCA) alone in our first experience (July 1994 to December 1995) and/or coronary artery stenting since January 1996.

The aim of this study was to assess a Doppler-echocardiographic parameter which has not been previously reported for the diagnosis of acute cardiac rejection. The parameter was left ventricular isovolumic relaxation blood flow. Eighty patients who had undergone orthoptic cardiac transplantation were followed up regularly with echocardiography for a period of 2 years. In all, 495 echocardiographic studies were performed and the results compared with those of endomyocardial biopsy performed on the same day (11.4 echocardiographic studies per patient). In the absence of cardiac rejection, isovolumic relaxation Doppler signal was recorded in all patients (364/387 echo studies). This was a positive signal directed towards the apex detected by continuous mode Doppler in the apical position, arising along the interventricular septum in the mid part of the left ventricle (82% of cases) or from the basal region of the septum (18% of cases) and lasting throughout the phase of isovolumic relaxation. The maximal velocity was 0.53 +/- 0.08 m/s (range 0.32 to 0.73 m/s) : the velocity-time integral was 34 +/- 33 cm. This signal was associated with medioventricular endosystolic acceleration of blood flow in 75% of cases. The incidence of the isovolumic relaxation flow signal decreased in cardiac rejection with no significant changes in the other usual Doppler-echocardiographic parameters except for a significant decrease in the ejection fraction in the group with severe rejection. In the group with mild rejection (n = 89) an isovolumic relaxation flow signal was only observed in 52 cases (including 29 in whom immunosuppressive treatment was not increased). In patients with moderate rejection (n = 12) there were only 5 cases in which a isovolumic relaxation flow signal was recorded, and in the group with severe rejection (n = 7), the signal could only be recorded in 1 case. The authors conclude that the absence of an isovolumic relaxation blood flow signal in a cardiac transplant patient is a reliable sign of cardiac rejection with an excellent specificity (94%). The absence of this signal is a sensitive indicator of severe rejection (86%) but less so for moderate (58%) or mild rejection (42%).

The value of Dobutamine stress echocardiography in the detection of coronary artery disease in heart transplant patients was studied in 64 patients at control coronary angiography 39 +/- 14 months after transplantation. Dobutamine was infused at progressively increasing doses (5 to 40 micrograms/kg/min) at 5 minute intervals, in order to reach 85% of the theoretical maximal heart rate or an ischaemic event. Echocardiography was analysed in the 4 standard views which were digitised allowing calculation of a regional wall motion score under basal conditions and at peak dosage in 16 left ventricular segments. Coronary angiography identified three groups: group I: 29 patients with normal coronary arteries; group II: 17 patients with non-significant coronary disease (diffuse or localised stenosis50%); group III: 9 patients with significant (50%) coronary disease. Dobutamine stress echocardiography showed regional wall motion abnormalities in 2/29 patients in group I, 13/17 patients in group II and all patients in group III (global sensitivity: 85%; specificity: 97%). The contractility score was significantly higher under basal conditions in group III (1.45 +/- 0.54) than in group I (1) and group II (1.17 +/- 0.23). At peak dose, the contractility score was unchanged in group I and increased significantly (p0.01) in the other two groups. The authors conclude that Dobutamine echocardiography is a reliable, non-invasive method of detecting coronary disease in cardiac transplant patients, and is particularly valuable for demonstrating myocardial ischaemia related to coronary lesions judged to be not significant at coronary angiography.

The authors report the case of a large right atrial thrombosis causing acute cardiac failure in an 18 year old patient with tricuspid atresia who had undergone 3 operations: Waterston shunt at 2 months of age, Fontan procedure at 3 years of age with reoperation at 13 years of age. The diagnosis was made at echocardiography and angiography. Surgical management comprised ablation of the thrombus and a tunneling of the right atrium between the inferior vena cava and the atriopulmonary conduit. The immediate postoperative course was complicated by a slowly regressive neurological deficit. The medium-term outcome (one year) is satisfactory with antiarrhythmic and anticoagulant therapy. A review of the literature showed that these thromboses are not exceptional in the early postoperative period for a variety of reasons. Secondary thrombosis is often related to arrhythmias, thus requiring clinical, electrocardiographic and echocardiographic follow-up of these patients and the prescription of antiarrhythmic and anticoagulant therapy. The diagnostic methods are discussed. Echocardiography may be sufficiently explicit to make potentially risky angiography unnecessary.

The authors report the case of a 33 year old patient, who underwent an emergency repair of a traumatic tear of the thoracic aorta, after a car accident. This operation was carried out with femoro-femoral cardiopulmonary bypass support. Associated lesions were traumatic tear of the left diaphragm repaired through left thoracotomy during repair of the aorta, rupture of the liver and multiple fractures of the left superior limb. Postoperative course was marked by liver hemorrhage and septicemia. Orthopedic treatment of the various fractures was performed. The course of thoracic lesions was uneventful. An aneurysm of the aortic isthmus was revealed during venous digital subtraction angiography routinely performed 60 days after surgery. The patient was reoperated with femoro-femoral bypass support. A second incomplete tear of the aorta, missed during the first operation was discovered 3 cm above the suture of the first one. This lesion was easily repaired and the post-operative course was uneventful. The value of systematic control angiography after aortic traumatic repair is emphasised.

The authors report the case of a 30-year old man who suffered spontaneous rupture of the right subclavian artery. Treatment consisted of carotid-axillary graft since the fragility of the vessel precluded direct suture. The clinical symptoms, together with histological and ultrastructural examinations led to a diagnosis of Ehlers-Danlos syndrome with purely arterial manifestations.