[Diagnosis of a systolic murmur among young asymptomatic patient: An assessment of professional practices for the expertise in military medicine]. / Diagnostic d'un souffle systolique cardiaque chez un jeune patient asymptomatique : une évaluation des pratiques professionnelles en médecine militaire d'expertise.

UNLABELLED: The finding of a systolic heart murmur is common in medical military practice. Albeit often benign among young healthy adults, it can reveal a valvular or a cardiac disease, which could worsen during workout or expose to risk of a sudden death. This study aims to evaluate the diagnostic efficiency of the military general practitioner when discovering a systolic murmur among young asymptomatic patients. MATERIALS AND METHODS: During one year, this study involved all the general practitioners of the medical military centres of Brittany and the cardiologists of the military hospital in Brest. It prospectively enrolled a cohort of all military asymptomatic patients under 40, without any underlying known heart condition. Military general practitioners listed, thanks to an anonymous form, the main features of the systolic murmur and of the ECG and proposed an auscultatory diagnosis: innocent or organic murmur. Then cardiologists did the same and finally performed a transthoracic echocardiography giving the diagnosis. RESULTS: Fifty-eight patients were referred, 5 not meeting the inclusion criteria. Of the 53 patients included, military general practitioners found 46 innocent murmurs and 7 organic ones. Cardiologists found 51 innocent murmurs and 2 organic. Transthoracic echocardiography just took on one organic murmur (linked with a bicuspid aortic valve), spotted by the specialist, though judged innocent by the general practitioner. DISCUSSION: Most of innocent murmurs diagnosed by general practitioners (45/46) were confirmed. Regarding the seven organic murmurs, the main selected criteria (intensity over 3, orthostatic persistence, diffuse irradiation) are mostly in accordance with the literature, proving right medical instincts. Authors propose a practical management of systolic murmurs among asymptomatic young patients. CONCLUSION: Military general practitioners seem to master symptoms of organic murmur. This assessment argues for a promotion of a holistic clinical examination, which will help not only to rationalize the use of transthoracic echocardiography in economic terms but also to value the medical expertise.

[Echographic diagnosis of systolic murmur among 280 young French militaries. Implications for the expertise in military medicine]. / Diagnostic échographique d'un souffle cardiaque systolique au sein d'une population de 280 jeunes militaires français. Implications en médecine d'expertise militaire.

UNLABELLED: Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries. METHODS: We ran a retrospective monocentric study in the "Clermont-Tonnerre" military hospital in Brest. We included all patients sent for TEE, aged 15 to 30 years old, from the 1st January 2010 until the 31st July 2013. RESULTS: Two hundred and eighty TTES assessing CSM were performed. We found 28/280 (10%) echocardiographic abnormalities: 13 were bicuspid aortic valves (4.6%), 6 were ventricular septal defects (2.15%), 3 were atrial septal defects (1.07%), 4 were mild mitral regurgitations (1.43%), one mild pulmonary stenosis (0.35%) and one aortic stenosis (0.35%). No hypertrophic cardiomyopathy was found. Concerning military expertise, 11 (3.92%) patients among these 28 with abnormal TEE were considered unfit for work or "fit for work with limitations". CONCLUSION: Assessing a cardiac systolic murmur with TEE lead to the diagnosis of a cardiomyopathy in 10% of the case. This study enhances the importance of systematic TEE when a CSM is detected in the young military, in order to determine if those soldiers can still fulfill their military duty.

[Practical conduct for patients with a lonely hypoxemia at rest or during exercise]. / Démarche diagnostique d'une hypoxémie « nue ¼ de l'adulte.

INTRODUCTION: Hypoxemia is a decrease in blood oxygen partial pressure. This work aims at presenting a practical conduct for patients with a lonely hypoxemia at rest or during exercise, defined by the absence of dyspnea at rest, obvious clinical or radiographic abnormality. STATE OF THE ART: Diagnostic tools available to the clinician are clinical examination, CT scan, echocardiography, hyperoxia test, trans cranial ultrasound and lung scintigraphy. This work proposes a practical diagnostic approach, with a main role of chest CT. PERSPECTIVES: Work is underway to determine more precisely the place of echocardiography for the diagnosis of intra or extra cardiac shunts. CONCLUSIONS: The finding of a lonely hypoxemia requires careful diagnostic approach to quickly rule out potentially serious causes and not to disregard the rare causes.

[Contribution of cardiac MRI in the initial evaluation and follow-up of myocarditis mimicking acute coronary syndrome: a series of 43 patients]. / Apport de l'IRM cardiaque dans l'évaluation initiale et le suivi des myocardites mimant un syndrome coronaire aigu : à propos d'une série de 43 patients.

AIMS: The diagnosis of acute myocarditis is complex, especially when the clinical presentation mimics an acute coronary syndrome. This condition may promote the progression to dilated cardiomyopathy and the occurrence of severe arrhythmias. A reassessment integrating a cardiac MRI at three months after the acute episode could help identify patients with a poor prognosis. PATIENTS AND RESULTS: This prospective series of 43 consecutive patients hospitalised for acute myocarditis included 36 men and seven women, with a mean age of 32 years, with no indication of heart failure. All patients presented elevated levels of troponin I. Echocardiography showed moderate left ventricular dysfunction in six cases and segmental wall motion abnormalities in 22 cases. After gadolinium injection, a subepicardial late enhancement was observed in 39 cases. Three months after the acute episode, all patients were asymptomatic. The echocardiography and laboratory tests were normal. In 23 cases, the MRI showed persistence of the late enhancement without segmental wall motion abnormality. After a mean follow-up of three years, one patient was lost to follow-up and only one suffered a heart failure revealing a dilated cardiomyopathy complicated by ventricular arrhythmias. CONCLUSION: On admission, the subepicardial localisation of late enhancement in the cardiac MRI is reliable criteria for the diagnosis of acute myocarditis, enabling to rule out an acute coronary syndrome. During follow-up, the persistence of late enhancement has no impact on prognosis. In this series, after a mean follow-up of three years, it was not associated with clinical or paraclinical abnormalities, except in one patient.

[Systematic implementation of transthoracic echocardiography, transesophageal echocardiography and 24-hour Holter ECG for the detection of cardiac sources of embolism in patients with stroke or transient ischemic attack. A retrospective study of 220 patients]. / Rentabilité diagnostique de l'échographie cardiaque transthoracique, transœsophagienne et du Holter ECG réalisés à titre systématique lors du bilan étiologique d'un premier accident vasculaire cérébral ischémique. Étude rétrospective de 220 patients.

INTRODUCTION: Embolism of cardiac origin accounts for around 20% of ischemic strokes. ECG and transthoracic echocardiography (TTE) are commonly obtained during the evaluation of patient of ischemic stroke but specific indications for the transesophageal (TEE) echocardiography and 24-hour Holter ECG (Holter) remain uncertain. OBJECTIVES: The aim of this study is to report the contribution of TTE, TEE and Holter performed as a routine during the evaluation of patients with ischemic stroke (IS) or transient ischemic attack (TIA). METHODS: This is a retrospective single-center study of 220 patients hospitalized between 1st January 2007 and 31st December 2010 for a first IS or TIA. RESULTS: One hundred and forty-three IS and 77 TIA are identified. The average age of patients was 66 years (18-88 years). TTE/TEE/24-hour Holter allowed the diagnosis of cardiac sources of embolism in 135 patents (61.3%). TTE/TEE identified potential source of cardiogenic embolism in 126 patients (52.2%). Twenty four-hour Holter ECG tracked supraventricular arrhythmia in 15 patients (6.7%), 9 (4%) which had non-contributory ultrasound assessment. CONCLUSION: The systematic implementation of TTE/TEE/Holter is useful for identifying potential sources of cardiogenic embolism. The performance of TEE remains above the TTE. Holter should be recommended because it is a cost effective and non-invasive tool.

[Lipomatous hypertrophy of the interatrial septum]. / Hypertrophie lipomateuse du septum interatrial.

Lipomatous hypertrophy of the heart is a benign rare tumor characterized by fatty tissue deposits in the interatrial septum. Its diagnosis during life is mostly seen incidental. We report the case of a 74-year-old female patient, in which a cardiac mass protruding in the right atrium was diagnosed by transthoracic echocardiography. Transoesophageal echocardiography examination detected an echogenic infiltration and hypertrophy of the interatrial septum, sparing the foramen ovale. The diagnosis of lipomatous hypertrophy of the interatrial septum is confirmed by MRI, which shows a well limited and not encapsulated tumor, appearing in increased signal density on T1-weighted images, and that decreases with fat-saturated sequences. This tumor did not enhance with the administration of contrast material. The benign and lipomatous nature of the lesion is confirmed, thus making the use of histology unnecessary.

[Cardiac extension of a non-Hodgkin lymphoma revealed by an atrial flutter]. / Flutter atrial révélateur de l'extension cardiaque d'un lymphome malin non hodgkinien.

Primary or secondary cardiac lymphomas are not frequent. Their clinical expression is unusual and the diagnosis is rarely made during the patient's life. Our case report, which is a slow atrial flutter with a pericardial effusion, is an uncommon discovery mode for a malignant lymphoma. Their diagnosis and the mechanism of the arythmia were allowed by non-invasive cardiac imagery (transesophageal echography and magnetic resonance imaging), which showed a tumour-like infiltration of the right atrium, of the right ventricle posterior wall, and of the atrioventricular junction. The diagnosis of a high grade B cell malignant non-hodgkin lymphoma, involving the bone marrow, the liver and the kidneys was made by biopsies of lymph nodes, histological analysis of the bone marrow, and a body CT scan. Throughout the first chemotherapy sequence, we observed a spontaneous return to a sinusal rhythm, and the cardiac MRI showed a regression of the myocardial infiltration and of the pericardial effusion; moreover, the patient's state improved and the peripheral lymph nodes shrank back to a normal size. However, the patient passed away, due to neurological complications 13 months after the diagnosis of lymphoma, without recurrence of cardiac involvement.

[Heavy-hearted: chronic constrictive pericarditis]. / "Un coeur serré": péricardite chronique constrictive.

The purpose of this report is to describe a case involving a 62-year-old Moroccan woman hospitalized for generalized edema that lead to diagnosis of chronic constrictive pericarditis. Diagnosis was confirmed on the basis of pericardial calcification and typical hemodynamic findings. New imaging techniques such as cardiac MRI allow accurate anatomical and physiological assessment in difficult cases. While tuberculosis is rarely involved in industrialized countries, it is a frequent factor in developing countries. The usual treatment consists of pericardectomy in association with standard antituberculosis drugs if association with tuberculosis is established or highly likely.

[Myocarditis caused by Trichinella spiralis: a case report]. / Myocardite à Trichinella spiralis: à propos d'un cas.

Trichinellosis is a cosmopolitan nematodosis which is rare in the developed countries. Myocarditis represents the most frequent form of cardiac complications, sometimes lethal. The authors report the observation of a 36-years-old patient admitted for trichinellosis, who presented asymptomatic electrocardiographic modifications and a rise in the troponine I. The magnetic resonance imaging (MRI) after gadolinium injection, highlighted an underepicardic late raising rendering the diagnosis of myocarditis highly probable. The paraclinic anomalies were corrected gradually under antiparasitarian treatment. Besides the EKG, the MRI is a non-invasive and repetitive method allowing as well the positive diagnosis as the follow-up of those patients.

[Complete atrioventricular block of the young adult... do not forget sarcoidosis]. / Bloc auriculoventriculaire complet du sujet jeune... Penser à la sarcoïdose.

The authors report the case of a 27 years old athletic patient, without any antecedents, presenting with a recent complete atrioventricular (AV block, disclosed by an effort dyspnoea and syncope. The electrophysiological exploration showed a nodal AV block. The magnetic resonance imaging revealed the existence of a septal hypersignal in T1 mode enhanced after Gadolinium injection, and left ventricular function normality. It also revealed the existence of a pulmonary parenchyma infiltrate, confirmed by thoracic scanner. Pathological examination of transbronchial biopsies showed noncaseating granuloma, consistent with sarcoidosis. Programmed electrical stimulation induced no ventricular arrhythmia. A dual chamber pace-maker was implanted because of the AV block permanence and the poor clinical tolerance, associated with steroid therapy (prednisolone 1 mg/kg/j). After a 18 months follow-up, the patient remains asymptomatic, and the 12-lead ECG shows a normal AV conduction. The authors discuss the different aetiologies of AVB, and emphasize to realize an exhaustive assessment in young adults. The cardiac localization disclosing sarcoïdosis and the complete AV block disappearance under therapy make that observation original. The occurrence of a complete AV block complicating sarcoidosis poses a management and prognosis problem.

[Arterial hypertension in sub-Saharan Africa. Update and perspectives]. / Hypertension artérielle en Afrique subsaharienne actualité et perspectives.

Arterial hypertension is a worldwide health problem due to its high incidence and to related cardiovascular and renal risks. More than 25% of adults in the world have hypertension and this percentage is expected to increase in the coming years in all areas including sub-Saharan Africa. There were approximately 80 million patients with hypertension sub-Saharan Africa in 2000 and projections based on current epidemiologic data suggest that this figure will rise to 150 million by 2025. The increase in the incidence of hypertension appears to be closely correlated with aging of the population as well as with the growing number of overweight and obese persons. Association with type II diabetes is particularly deleterious. These trends show regional variations with prevalence being associated with the rate of urbanization and westernization of lifestyle. In Black Africa hypertension presents several etiopathogenic particularities mainly with regard to dependence on sodium sensitivity and lower plasma renin activity. Due to delayed and/or inadequate therapeutic management and to a likely genetic predisposition, organ-related complications are more common and occur earlier in Black Africa. Stroke, heart failure, and renal failure are frequent complications in young patients. From a therapeutic standpoint, the mainstay treatment involves the use of thiazidic diuretics in association with hygiene and dietary measures especially sodium restriction. This article provides an update of recent findings in this domain.

[A study of cardiovascular risk factors associated with atherosclerosis of thoracic aorta detected by transesophageal echocardiography in Vietnam]. / Etude des facteurs de risque cardio-vasculaire associés à l'athérosclérose de l'aorte thoracique dépistée par échocardiographie trans-oesophagienne au Viêt-Nam.

This study was designed to assess the relationship between cardiovascular risk factors and the presence of atherosclerosis aortic lesions detected by transesophageal echocardiography (TEE), The purpose was to determine if risk factors observed in Vietnam are similar to those detected in industrial countries. Between 2000 and 2002, TEE was performed in a total of 181 patients with a mean age of 63.1 +/- 9.4 (range, 42 to 79). In male patients over the age of 60 years, smoking, hypertension, diabetes and dyslipidemia were associated with significantly greater thickness of the intima and significantly higher number of complex lesions at all levels of thoracic aorta. Presence of these risk factors was associated with a 4.2 to 7.9 fold higher likelihood of atherosclerotic plaque. Findings in our population of hospital patients in Vietnam indicate that, as in Western populations, age, male gender, smoking, arterial hypertension, diabetes, and hypercholesterolemia promote the appearance of plaques in the thoracic aorta. This study provides insight into the cardiovascular risk situation in a city in Southeastern Asia.

[Heart failure due to non-infectious causes in developing countries: etiologic approach and therapeutic principles]. / Insuffisance cardiaque d'origine non infectieuse en zone tropicale: approche étiologique et principes thérapeutiques.

Cardiovascular disease is a major worldwide health problem with a growing impact in developing countries. Heart failure is the clinical manifestation of many advanced cardiac disorders. It can have numerous etiologies and the incidence of non-infectious causes is increasing with socio-economic development, thus illustrating the global nature of this epidemiologic transition. Several of the numerous non-infectious causes of heart failure involve cardiac diseases specific to tropical areas including dilated cardiomyopathy, endomyocardial fibrosis, and peripartum cardiomyopathy. Other widespread disorders are becoming more common as a result of the epidemiologic transition. Cardiovascular risk factors are changing particularly with regard to the incidence of coronary artery disease, ischemic cardiomyopathy, and hypertension-related complications. The purpose of this article is to provide an overview of non-infectious causes of heart failure in terms of frequency, onset, and therapeutic requirements. Symptomatic treatment of heart failure is same as in developing countries but is often delayed due to shortcomings in the care system.

[Left ventricular noncompaction: a cardiomyopathy in young individuals. Description of first cases in Africa]. / La non compaction du ventricule gauche, une cardiomyopathie du sujet jeune: premieres observations Africaines.

Left ventricular noncompaction (LVNC) is a recently identified and probably rare congenital cardiomyopathy characterized by changes in the structure of the myocardium secondary to incomplete embryogenesis. The purpose of this report is to describe three cases of LVNC involving African patients. To our knowledge these are the first cases described in Africa. All three patients in this series were men from sub-Saharan Africa ranging in age from 23 to 45 years. The first patient in whom cardiomegaly was recognized on a routine chest x-ray was asymptomatic. The second who presented with exertional dyspnea developed left bundle branch block. The third was admitted to the hospital for acute pulmonary edema. In all three cases transthoracic echocardiography suggested diagnosis. The left ventricle was dilated and hypokinetic and the myocardium exhibited a spongy aspect in association with the presence of prominent trabeculations separated by crypts located at the apex and lateral wall. Color Doppler demonstrated that intratrabecular recesses were filled by intraventricular blood flow. Magnetic resonance imaging (MRI) specifically confirmed this morphological feature. Sudden death due to arrhythmia, cardiac insufficiency, and systemic emboli are the main complications of LVNC. The incidence of LVNC, which is certainly underestimated, is highest in young adults but it can be diagnosed at any age. Echocardiography and MRI are effective tools for detection of the morphologic diagnostic criteria. Recent evidence suggests that LVNC is of genetic origin and the data reported here shows that the underlying mutations are present in sub-Saharan populations. Family screening in African populations is still difficult. Therapeutic management is currently based on symptomatic treatment of cardiac insufficiency and can require techniques not readily available in tropical settings.

[Thoracic aortic dissection revealed by systemic cholesterol embolism]. / Dissection de l'aorte thoracique révélée par des embolies systémiques de cristaux de cholesterol.

Systemic cholesterol embolism is a rare complication of atherosclerosis, and has various presentations. Arterial catheterisms are a common cause. However, the association with an aortic dissection has been exceptionally reported. We report the observation of a 70 year-old man, with coronary artery disease, hypertension, diabetes and dyslipidemia. Six months before hospitalization, a coronary angioplasty was performed due to recurrent angina. The association of purpuric lesions on the feet, with acute renal failure confirmed cholesterol embolism syndrome. Transoesophageal echocardiography showed a dissection of the descending thoracic aorta associated with complex atheroma. The evolution was marked by the pulpar necrosis of a toe and by a worsening of the renal failure, requiring definitive hemodialysis. Further echographic control highlighted the rupture of the intimal veil of the dissection. Cholesterol embolism syndrome may reveal an aortic dissection in patients without thoracic symptoms. In such cases, transoesophageal echocardiography is a useful and non-invasive examination.

[Adult apico-aortic shunts. A case followed for 6 years]. / Dérivation apico-aortique chez l'adulte. A propos d'un cas suivi durant 6 ans.

An apico-aortic shunt enables a reduction in the aortic transvalvular pressure gradient. It is recommended for patients with symptomatic severe stenosis when anatomical constraints contra-indicate valvular replacement. The authors report the case of a patient who underwent this uncommon procedure, which was indicated due to previous coronary bypass surgery using both mammary arteries, plus massive calcification of the ascending aorta. Angio-haemodynamic investigation and MRI performed three years and five years respectively following the procedure confirmed its efficiency. An analysis of the few reported series confirms the value of this special procedure.