[Infectious endocarditis: strategy for diagnosis]. / Endocardites infectieuses : démarche diagnostique.

INFECTIOUS ENDOCARDITIS: STRATEGY FOR DIAGNOSIS. The diagnosis of infective endocarditis is often difficult because the clinical presentations are very heterogeneous. Epidemiology has evolved with more acute forms, different microorganisms, and an increase in prevalence in patients with cardiac prosthetic or electronic devices. Diagnosis is based on a clinical suspicion, associated with microbiological data and imaging evidence of lesions of the endocardium. Echocardiography plays a key role, but advanced imaging techniques provide additional information. The 2023 European Society of cardiology (ESC) recommendations like those of 2015 confirmed the essential role of multimodal imaging, integrating lesions highlighted by any imaging technique as major criteria. The diagnostic criteria have thus been modified to consider new epidemiological and imaging data. Different diagnostic strategy algorithms are proposed depending on whether the patient has prosthetic material or not. The endocarditis team is the keystone in this diagnostic approach to improve patient management.

ENDOCARDITES INFECTIEUSES: DÉMARCHE DIAGNOSTIQUE. Le diagnostic d'endocardite infectieuse est souvent difficile, car les présentations cliniques sont hétérogènes. L'épidémiologie a évolué avec des formes plus aiguës, des micro-organismes différents et avec l'augmentation de la prévalence chez les patients porteurs de matériel intracardiaque. Le diagnostic repose sur une suspicion clinique supportée par des données microbiologiques et la mise en évidence de lésions de l'endocarde à l'imagerie. L'échocardiographie joue un rôle clé, mais les techniques avancées d'imagerie permettent d'améliorer les performances diagnostiques. Les recommandations de l'European Society of Cardiology (ESC) 2023, comme celles de 2015, ont confirmé le rôle essentiel de l'imagerie multimodale, intégrant comme critères majeurs les lésions mises en évidence par toute technique d'imagerie. Les critères diagnostiques ont été ainsi modifiés pour prendre en compte les nouvelles données épidémiologiques et d'imagerie. Différents algorithmes de stratégie diagnostique sont proposés selon que le patient est porteur de matériel prothétique ou non. L'équipe multidisciplinaire d'endocardite est la clé de voûte dans cette démarche diagnostique pour améliorer la gestion des patients.

Eversion for Stabilization: A Standardized Technique for Pulmonary Autograft Inclusion.

We have developed a new technique avoiding autograft distortion and narrowing at inclusion during Ross procedure, in order to preserve the functional anatomy and the process of adaptation.

Long-term evolution of stents implanted in branch pulmonary arteries.

BACKGROUND: Branch pulmonary artery stenosis complicates the management of congenital heart diseases. Surgical branch pulmonary artery angioplasty is associated with a high reintervention rate. As an alternative, percutaneous or intraoperative branch pulmonary artery stents have been implanted to improve efficiency, but long-term evaluations are limited. AIM: To describe the long-term evolution of branch pulmonary artery stents. METHODS: We conducted a retrospective cohort study at Tours University Hospital. All stents implanted by surgery or catheterization in branch pulmonary arteries with a minimum follow-up of 12 months and at least one catheterization control were included. The primary endpoint combined cardiovascular mortality, surgical or percutaneous reintervention for stent complication or new stent implantation. RESULTS: Between 2007 and 2017, 76 stents in 51 patients were included (62 stents implanted by surgery, 14 by catheterization). At implantation, the patients' mean age and weight were 4.7years (interquartile range 4.2years) and 17.3kg (interquartile range 11.0kg), respectively. Mean branch pulmonary artery minimum diameter was 4.1±2.1mm (mean Z-score-4.9±2.9), and mean initial stent diameter was 9.1±3.1mm. During a follow-up of 5.3years (range 0-11.2 years), freedom from primary endpoint was 86.8% (95% confidence interval 79.6-94.8%) at 1 year, 71.5% (95% confidence interval 61.9-82.7%) at 5years and 69.6% (95% confidence interval 59.6-81.2%) at 10 years. We did not identify any factors associated with major adverse cardiovascular events. Among stents without major adverse cardiovascular events, the mean branch pulmonary artery diameter Z-score at last evaluation had increased by +4.8±3.2 compared with the initial diameter (P<0.001). After stent implantation, a median of 2 re-expansions were performed for each stent (range 0-7). CONCLUSIONS: Stent implantation should offer a good long-term solution for branch pulmonary artery stenosis, although iterative re-expansions are required.

Perforation of the atretic pulmonary valve using chronic total occlusion (CTO) wire and coronary microcatheter.

BACKGROUND AND OBJECTIVE: Chronic total occlusion (CTO) guidewire have been recently reported as an alternative to radiofrequency for perforating atretic pulmonary valve. Since procedure failures or perforation of the right ventricle still occurred with CTO, we tried to enhance the stability, steering, and pushability of the wire using a microcatheter in order to improve the safety and efficacy of the procedure. METHODS: We performed pulmonary valve perforation with CTO guidewire and microcatheter in five consecutive newborns with pulmonary atresia with intact ventricular septum (PA-IVS) under fluoroscopic and echocardiographic control. RESULTS: The valve was easily perforated at the first attempt for all patients. After perforation, the microcatheter positioned in the main pulmonary artery allowed the exchange of the CTO guidewire for a more flexible wire, avoiding lesion and facilitating manipulation in the distal pulmonary branch arteries. The pulmonary valve was then dilated with balloons of increasing size as usually performed. We did not experience any procedural or early complications. Blalock-Taussig shunt was performed in 2 children because of a persistent cyanosis, 4 and 10 days after perforation. CONCLUSIONS: The combined use of a CTO guide and a microcatheter appears to be a safe and reliable technique for perforating the pulmonary valve of newborns with PA-IVS. Further procedures with this approach are needed to confirm this first experience.

Evaluation of the efficacy of a self-training programme in focus cardiac ultrasound with simulator.

BACKGROUND: Focus cardiac ultrasound is a great tool for quick evaluation of cardiac function in acute settings with limited time and expertise in echocardiography. Adequate training is essential for physicians willing to use this imaging technique. AIM: The goal of this study was to assess the efficacy of a self-training programme using a cardiac ultrasound simulator. METHODS: Thirty-five trainees in cardiology, emergency medicine or anaesthesiology entered the programme, which started with an e-learning lecture on focus cardiac ultrasound, with practice on a simulator, followed by implementation on patients, and ended with self-training in image analysis on an online platform. A post-test evaluation was carried out at the end of the theoretical training, followed by a final live evaluation on patients (timed acquisition of the five reference views used in focus cardiac ultrasound, grading each view on a scale of 1 to 5). Trainees were also evaluated online regarding their interpretation of 20 video clips. RESULTS: The median (interquartile range) interpretability scores following simulator training were 5 (4-5) for the parasternal long-axis view, 5 (4-5) for the apical four-chamber view, and 4 (4-5) for the subcostal window. Interpretability was significantly inferior in the live evaluation compared with the post-test evaluation, except for the parasternal long-axis and subcostal views. The mean score for the video clips (out of 20) was 14.5±2.4. CONCLUSIONS: After a short self-training programme, trainees were able to acquire the main views of focus cardiac ultrasound with sufficient quality and in a short time period.

Unexpected low prevalence of atrial fibrillation in cryptogenic ischemic stroke: a prospective study.

PURPOSE: Ischemic stroke is a frequent pathology with high rate of recurrence and significant morbidity and mortality. There are several causes of stroke, affecting prognosis, outcomes, and management, but in many cases, the etiology remains undetermined. We hypothesized that atrial fibrillation was involved in this pathology but underdiagnosed by standard methods. The aim of the study was to determine the incidence of atrial fibrillation in cryptogenic ischemic stroke by using continuous monitoring of the heart rate over several months. The secondary objective was to test the value of atrial vulnerability assessment in predicting spontaneous atrial fibrillation. METHODS AND RESULTS: We prospectively enrolled 24 patients under 75 years of age, 15 men and 9 women of mean age 49 years, who within the last 4 months had experienced cryptogenic stroke diagnosed by clinical presentation and brain imaging and presumed to be of cardioembolic mechanism. All causes of stroke were excluded by normal 12-lead ECG, 24-h Holter monitoring, echocardiography, cervical Doppler, hematological, and inflammatory tests. All patients underwent electrophysiological study. Of the patients, 37.5% had latent atrial vulnerability, and 33.3% had inducible sustained arrhythmia. Patients were secondarily implanted with an implantable loop recorder to look for spontaneous atrial fibrillation over a mean follow-up interval of 14.5 months. No sustained arrhythmia was found. Only one patient had non-significant episodes of atrial fibrillation. CONCLUSION: In this study, symptomatic atrial fibrillation or AF with fast ventricular rate has not been demonstrated by the implantable loop recorder in patients under 75 years with unexplained cerebral ischemia. The use of this device should not be generalized in the systematic evaluation of these patients. In addition, this study attests that the assessment of atrial vulnerability is poor at predicting spontaneous arrhythmia in such patients.