Migraine with aura and silent brain infarcts lack of mediation of patent foramen ovale.

BACKGROUND AND PURPOSE: Population-based studies have shown a heightened prevalence of clinically silent brain infarcts in subjects who have migraine with aura (MA). We sought to determine whether this association could be confirmed in young patients with cryptogenic ischemic stroke, and explored the role of patent foramen ovale (PFO) as a potential underlying mechanism. METHODS: Patients were selected from a registry of young patients consecutively treated for ischemic stroke in a tertiary university hospital among those without definite cause of stroke. Patients with PFO were matched for age and gender with patients with normal atrial septum. Migraine and MA were evaluated after patient selection and matching. Silent brain infarcts were independently evaluated on MRI. RESULTS: We included 100 patients [60 men; mean age (SD), 44.8 years (8.3)], 50 patients with PFO. We found silent brain infarcts in 36 patients and MA in 13 patients. MA was more frequent in patients with silent brain infarcts than in patients without silent brain infarcts (25.0% vs. 6.3%; OR, 5; 95% CI, 1.4-17.6; P = 0.01). Traditional cardiovascular risk factors were not associated with silent brain infarcts. PFO was neither associated with MA (OR, 1.7; 95% CI, 0.5-5.3) nor silent brain infarcts (OR, 0.7; 95% CI, 0.3-1.5). The association of MA with silent brain infarcts was not altered after adjustment for PFO. CONCLUSION: Findings suggest that silent brain infarcts in young patients with cryptogenic stroke is associated with MA. We found no evidence for a mediating effect of PFO on this association.

Patent foramen ovale and ischemic stroke.

Patent foramen ovale (PFO) is a common finding in healthy subjects and has not been associated with increased risk of ischemic stroke in population-based cohort studies. Nevertheless, case-control studies have consistently shown an increased prevalence of PFO in cryptogenic stroke, suggesting that PFO might be a cause of stroke. The risk of stroke recurrence in patients with cryptogenic stroke and PFO is low under aspirin therapy but may be substantially higher in patients with an associated atrial septal aneurysm (ASA). The mechanisms of stroke associated with PFO or ASA are uncertain. Paradoxical embolism through the PFO is rarely documented. The optimal treatment for secondary prevention in patients with cryptogenic stroke and PFO is still uncertain and debated. A randomized controlled trial failed to demonstrate the superiority of transcatheter PFO closure over medical therapy. Whether anticoagulation is superior to aspirin should be tested in a randomized controlled trial.

DBH deficiency in an elderly patient: efficacy and safety of chronic droxidopa.

We describe the effects of chronic droxidopa in a patient with Dopamine beta-hydroxylase deficiency diagnosed at the age of 73. Investigations were performed to assess sympathetic activity (MIBG scintigraphy, catecholamines) and cardiovascular droxidopa safety.

The importance of imaging assessment before endovascular repair of thoracic aorta.

Indications for and experience with placement of endovascular stent grafts in the thoracic aorta are still evolving. Recent advances in imaging technologies have drastically boosted the role of pre-procedural imaging. The accepted diagnostic gold standard, digital subtraction angiography, is now being challenged by the state-of-the-art computed tomography angiography (CTA), magnetic resonance angiography (MRA) and trans-oesophageal echocardiography (TEE). Among these, technological advancements of multidetector computed tomography (MDCT) have propelled it to being the default modality used, optimising the balance between spatial and temporal resolutions and invasiveness. MDCT angiography allows the comprehensive evaluation of thoracic lesions in terms of morphological features and extent, presence of thrombus, relationship with adjacent structures and branches as well as signs of impending or acute rupture, and is routinely used in these settings. In this article, we review the current state-of-the-art radiological imaging for thoracic endovascular aneurysm repair (TEVAR), especially focusing on the role of MDCT angiography. After analysing the technical aspects for optimised imaging protocols for thoracic aortic diseases, we discuss pre-procedural determinants of candidacy, and how to formulate interventional plans based on cross-sectional imaging.

Prevalence of atrial septal abnormalities in older patients with cryptogenic ischemic stroke or transient ischemic attack.

OBJECTIVE: To evaluate the association of atrial septal abnormalities--patent foramen ovale (PFO), atrial septal aneurysm (ASA), or the combination of both (PFO+ASA)--with cryptogenic stroke or transient ischemic attack (TIA) in older patients. METHODS: We examined the prevalences of PFO, ASA, and PFO+ASA in 132 consecutive patients aged 55 years or more who underwent transesophageal echocardiography (TEE) for evaluation of ischemic stroke or TIA. We compared patients with cryptogenic stroke/TIA and those with stroke/TIA of known cause. RESULTS: PFO+ASA was more common in patients with cryptogenic stroke/TIA than in patients with stroke/TIA of known cause (12/62 or 19% vs. 2/70 or 3%; adjusted odds ratio, 7.4; 95% CI, 1.4-38.2). Differences between groups for isolated PFO, and isolated ASA were not significant. The association of PFO+ASA with cryptogenic stroke/TIA was confirmed in the subgroup of patients aged 75 years or more (odds ratio, 15.0; 95% CI, 1.5-146.7). CONCLUSION: This study indicates a significant association of PFO+ASA with cryptogenic stroke or TIA in older patients.

[Percutaneous closure of three septal defects by two Amplatz occluders implanted during the same procedure]. / Fermeture percutanée de 3 communications interauriculaires par 2 dispositifs d'Amplatz implantés au cours d'un même cathétérisme.

Multiple atrial septal defects can be closed by interventional catheterisation. The procedure requires an accurate morphological evaluation: number of defects, distance from their edges to the main cardiac structures, resistance of the septum. The authors report the case of a 63 year old woman presenting with cardiac failure in whom 3 atrial septal defects were diagnosed. All 3 defects were successfully closed by the implantation of two Amplatz devices. Control echocardiography at 6 months showed the occluders in a normal position with no residual shunt and the patient was asymptomatic.

[Endografts (or stent-grafts) and diseases of the descending thoracic aorta]. / Endoprothèses (ou stent-grafts) et pathologies de l'aorte thoracique descendante.

The endovascular treatment of aorta diseases with S-Graft is considered as an alternative to surgery, especially interesting in patients with severe comorbidities. Indeed, the mid-term morbidity and mortality are comparable to surgery in relatively large series, and S-Graft implantation appeared as a safe, less invasive and efficient treatment for different affections of the thoracic aorta. This article reviews technical aspects, indications and results of endovascular repairs of thoracic aorta lesions. We will also assess the advantages and limitations of S-Graft therapy.

Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair.

OBJECTIVE: The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS: A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS: In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS: In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

[Echocardiography and the painful aorta]. / Echocardiographie et aorte douloureuse.

The acute painful aortic syndrome is a clinical enity observed in four conditions: dissection, intramural haematoma, penetrating atheromatous ulcer and aneurysm. The diagnosis is based on three imaging techniques: echocardiography, CT scan and magnetic resonance imaging. They have displaced angiography which is incomplete and even dangerous in some cases. Their sensitivity and specificity are comparable in terms of diagnosis. However, each has a specificity. Transthoracic and transoesophageal echocardiography are useful in the diagnosis, the quantification and analysis of the mechanism of aortic regurgitation which may complicate dissection. CT scan visualises the collateral arteries, investigates the physiopathological mechanisms of poor perfusion syndromes and detects parietal fissuration. Magnetic resonance imaging is better adapted to the study of stable forms. In conclusion, transoesophageal echocardiography is a rapid and reliable diagnostic method, it can be used as the investigation of first intention and is essential in patient management. The use of other imaging modes is only required in some cases. The choice, guided by the clinical history, depends on its aptitude to complete the missing or partial data of transoesophageal echocardiography.

[Obesity and cardiac failure]. / Obésité et insuffisance cardiaque.

Obesity alone is the cause of 11% of cases of cardiac failure in men and 14% of cases in women in the United States. The frequency of obesity continues to rise in our country, 41% of our compatriots being obese or overweight. It is expected that obesity will become an important cause of cardiac failure in the coming years. The Framingham study showed that, after correction for other risk factors, for every point increase in body mass index, the increase in risk of developing cardiac failure was 5% in men and 7% in women. There are three physiopathological mechanisms to explain the adverse effects of obesity on left ventricular function: an increase in ventricular preload secondary to increased plasma volume induced by the high fatty mass; an increase in left ventricular afterload due to the common association of hypertension generated by activation of the sympathetic nervous system by hyperinsulinism; and systolic and diastolic dysfunction due to changes in the myocardial genome and coronary artery disease induced by risk factors of atherosclerosis aggravated by obesity. The adipocyte also secretes a number of hormones which act directly or indirectly on the myocardium: angiotensin II, leptin, resistin, adrenomedulin, cytokines. These haemodynamic and hormonal changes profoundly modify the genetic expression of the myocardium in obesity, favourising hypertrophy of the myocyte and the development of interstitial fibrosis. Whether it be eccentric in the absence of hypertension or concentric when hypertension is associated with obesity, left ventricular hypertrophy, although normalising left ventricular wall stress, has adverse consequences causing abnormal relaxation and decreased left ventricular compliance. Therefore, in obese patients, two forms of cardiac failure may be observed. The more common is due to diastolic dysfunction, obesity being one of the principal causes of cardiac failure with preserved systolic function. Cardiac failure due to systolic dysfunction is less common and may be observed in cases with inappropriate left ventricular hypertrophy which does not normalise abnormal left ventricular wall stress leading to cardiomyopathy, and in cases with associated coronary artery disease. Whatever the underlying mechanism, the diagnosis of cardiac failure is made more difficult by obesity. From the prognostic point of view, in the global population of patients with cardiac failure, obesity improves survival because it counteracts the adverse effect of cachexia; however, obesity increases the risk of sudden death. In fact, obesity is associated with dynamic change in QT interval. In cases of cardiac failure secondary to obesity-related cardiomyopathy, loss of weight leads to an improved functional status and a reduction of left ventricular remodelling and an increase of the ejection fraction.

[Cardiac cellular therapy: from cells to the first clinical uses]. / Thérapie cellulaire cardiaque: des cellules aux premières indications cliniques.

Despite the improvement in revascularisation techniques, coronary artery disease remains the principal aetiology of cardiac failure in developed countries. The therapeutic management of cardiac failure has been improved over recent years, yet cardiac failure is still associated with significant morbidity and mortality. As cardiac transplantation lacks donors, techniques that allow myocardial regeneration represent an attractive alternative. To date, several types of cells are under study and are suitable for implantation into infarcted myocardium (myoblasts, medullary stem cells...). Following good preclinical study results, the first human cell therapy trials, using the intramyocardial route, have begun, in the course of aorto-coronary bypass surgery in patients with chronic ischaemic cardiopathy and little altered left ventricular function, and then in those with ventricular dysfunction. Different modes of administration of these cell therapy products are under study and could be envisaged in clinical situations such as just after infarction in order to improve ventricular remodelling with an intracoronary injection technique. As for every new treatment, there are numerous problems to resolve, from understanding the relevant mechanisms of cellular transplantation, to the secondary effects that it could entail. Nevertheless, cardiac cellular transplantation is expanding rapidly and with the evolution of techniques it allows a glimpse of a new field of treatment for cardiac failure.

Changes in short-term variability of blood pressure and heart rate during the development of obesity-associated hypertension in high-fat fed dogs.

OBJECTIVE: To investigate the nature and time course of autonomic nervous system changes elicited by a 21-week ad libitum high-fat diet (HFD) in dogs. RESULTS: The HFD increased body weight (+22.0+/-2.8% at week 21) with an abdominal circumference gain significantly more elevated than the thoracic one. The increases in insulin and free fatty acid plasma levels were correlated with body weight changes. Systolic and diastolic blood pressures and heart rate significantly increased (+23+/-6, +28+/-5 and 19+/-9% respectively). Arterial hypertension was characterized by an increase in cardiac output (+22.3+/-7.7%), in left ventricular mass (+18.1+/-5.0% at week 21) and a decrease in spontaneous baroreflex efficiency (-55+/-6%). The time course of autonomic changes (using spectral analysis of systolic blood pressure and heart rate) showed the existence of time-dependent modifications, which were linked with food intake. The initial rise in arterial blood pressure during body weight increment (observed between the 1st and 8th week of HFD) was associated with a transient increase in the low frequency band of systolic blood pressure variability and noradrenaline plasma levels associated with a long-lasting decrease in the high frequency band of heart rate variability. Early changes in short-term variability were significantly correlated with free fatty acid plasma levels. In contrast, the steady-state of obesity-related hypertension was associated with a decreased high frequency band of heart rate variability, without significant changes in noradrenaline plasma levels. CONCLUSIONS: This study shows that the HFD induces abdominal obesity, hyperinsulinaemia and arterial hypertension, with a left ventricular hypertrophy associated with a biphasic changes in autonomic activity: an early and long-lasting decrease in parasympathetic nervous system activity and an early but transient increase in sympathetic activity. The present data suggest that autonomic nervous system changes are dependent on the time course of obesity development.

Prognostic value of ventricular arrhythmias in systemic hypertension.

OBJECTIVE: Hypertensive left ventricular hypertrophy is associated with an increased risk of arrhythmias and mortality. However, no clinical study has demonstrated a significant relationship between ventricular arrhythmias and mortality in systemic hypertension. DESIGN AND METHODS: To evaluate the prognostic value of arrhythmogenic markers, we included, prospectively, 214 hypertensive patients aged (mean+/-SD) 59.1+/-12.8 years, without symptomatic coronary disease, myocardial infarction, systolic dysfunction or electrolyte disturbances. At inclusion, a 12-lead electrocardiogram (ECG) with QT dispersion calculation, a 24 h Holter ECG (204 patients) with Lown classification of ventricular arrhythmias, echocardiography (reliable in 187 patients) and a signal-averaged ECG (125 patients) with ventricular late potentials were recorded. RESULTS: At baseline, echocardiographic left ventricular hypertrophy was found in 63 patients (33.7%). Non-sustained ventricular tachycardia (Lown class IVb) was recorded in 33 patients (16.2%) and late potentials in 27 patients (21.6%). After a mean follow-up of 42.4+/-26.8 months, all-cause mortality was 11.2% (24 patients); 17 patients died of cardiac causes (7.9%); of these, nine (4.2%) died suddenly. In univariate analysis, age, Lown class IVb and a QT dispersion > 80 ms were significantly related to global, cardiac and sudden death (P < 0.01). The left ventricular mass index was related to cardiac mortality (P= 0.002). In multivariate analysis, only Lown class IVb was an independent predictor of global and cardiac mortality, increasing the risk of global death 2.6-fold (95% confidence interval 1.2-6.0) and cardiac death 3.5-fold (95% confidence interval 1.2-9.7). CONCLUSION: In hypertensive patients the presence of non-sustained ventricular tachycardia has prognostic value.

Aortic stent grafting and side-branch embolization in an expanding chronic type B dissection.

OBJECTIVE: This is a report of endovascular treatment of a case of type B thoracoabdominal aortic dissection in a patient with progressive dyspnea, dorsolumbar pain, and expanding aortic diameter over a 1-year period. METHODS: Pretreatment imaging evaluation showed that the false lumen supplied only the celiac trunk. Endovascular treatment combined (1) embolization of the first segment of the celiac trunk to avoid distal back-flow into the false lumen and (2) stent grafting to occlude the initial entry tear. RESULTS: The treatment resulted in technical and clinical success. The patient remains asymptomatic 12 months after treatment. CONCLUSION: Stent grafting offers an interesting therapeutic alternative to exclude the initial entry tear in aortic dissection and may be combined with other endovascular procedures.

Asymptomatic cerebral embolic signals in patients with acute cerebral ischaemia and severe aortic arch atherosclerosis.

Severe aortic arch atheroma (AAA) is a strong risk factor for ischaemic stroke, but it is unclear whether AAA is a source of cerebral emboli or simply a marker of cerebral atherosclerosis. The purpose of this study was to find out the prevalence of asymptomatic cerebral embolic signals (ES) in patients with acute cerebral ischaemia, AAA and no other potential source of cerebral embolism. Forty patients with anterior circulation ischaemic stroke or transient ischaemic attack (TIA) were prospectively studied using transesophageal echocardiography (TEE) and transcranial Doppler (TCD) scanning within seven days of symptom onset. Patients with a cardiac source of embolism or carotid stenosis > 50% were excluded. ES were detected in 14.3% (2/14) of patients with AAA > or = 4 mm and in no patients with AAA < 4 mm or no AAA (p=0.14). The findings suggest that ES may be associated with severe AAA but their prevalence is low in this setting.

Prognostic value of heart rate variability in time domain analysis in congestive heart failure.

AIMS: Analysis of heart rate variability is a noninvasive tool that allows to study autonomic control of the heart. Several studies have shown disturbed heart rate variability in patients with chronic heart failure (CHF). We sought to assess the prognostic value of time domain measures of heart rate variability in CHF. METHODS AND RESULTS: We prospectively enrolled 190 patients with CHF in sinus rhythm, mean age 61+/-12 years, 109 (57.4 %) in NYHA class II and 81 (42.6 %) in class III or IV, mean cardiothoracic ratio 57.6+/-6.4 % and mean left ventricular ejection fraction 28.2+/-8.8 %, 85 (45 %) with ischemic and 105 (55 %) with idiopathic dilated cardiomyopathy. Time domain measures of heart rate variability were obtained from 24 h Holter ECG recordings. During follow-up (22+/-18 months), 55 patients died. In multivariate analysis, independent predictors for all-cause mortality were: ischemic heart disease, cardiothoracic ratio > or =60 % and standard deviation of all normal RR intervals <67 ms (RR=2.5, 95 % CI 1.5--4.2). CONCLUSIONS: Depressed heart rate variability has independent prognostic value in patients with CHF.

Cardiac damage in nonpenetrating chest injuries. Report of 5 cases.

The Authors report 5 cases of cardiac injury after blunt chest trauma: (a) one right atrial disruption with acute tamponade treated successfully; (b) two left ventricular perforations with rib fractures: one patient was exsanguinated and died, the other one presented a late subacute cardiac tamponade with successful operative repair; (c) one isolated traumatic tricuspid insufficiency which was well tolerated; (d) one atrio-inferior caval disruption with acute tamponade. Cardiac damage secondary to nonpenetrating chest trauma is uncommon but with the present modes of high speed transportation they are occurring with increasing frequency; correct management of cardiac ruptures depends upon rapid recognition of the injury and expeditious surgical repair. The occurrence of tricuspid valvular lesions alone as a result of nonpenetrating trauma is not common. Echocardiographic examination after blunt chest trauma is a useful diagnosis procedure.

[Concentric left ventricular hypertrophy in patients with hypertension. When should ventricular hyperexcitability be searched for?]. / Hypertrophie ventriculaire gauche concentrique chez l'hypertendu. Quand rechercher une hyperexcitabilité ventriculaire?

The main objective is to determine when concentric left ventricular hypertrophy (LVH) increased ventricular ectopic activity in essential hypertension. Twenty-four hours Holter monitoring was recorded in 56 patients with essential hypertension: 20 without LVH and 36 with concentric LVH determined by echocardiography (left ventricular mass greater than 215 g). According the degree of septal thickness (ST), patients were classed in 4 groups: (formula; see text) This study allows to conclude that mean and severe concentric LVH (ST greater than or equal to 12) detected by echo are associated with a greater PVC and a higher Lown's class ventricular ectopy. The degree of ST was strong correlated with the Lown's classification (r = 0.6, p less than .0001).

[Ambulatory blood pressure monitoring and left ventricular hypertrophy: correlations and trial of predictive value]. / Enregistrement tensionnel ambulatoire et hypertrophie ventriculaire gauche: corrélations et tentative de prédiction.

The purpose of the study is to make a selection of patients with left ventricular hypertrophy from Ambulatory Blood Pressure Monitoring (ABPM) values. We studied 39 patients, 23 men and 16 women, without treatment. These patients had systolic pressure > 140 mmHg and/or diastolic pressure > 90. With ABPM we measured mean systolic (MS) and diastolic (MD) pressure during the day (D) and the night (N), the percentages of systolic values (%S) > 160 mmHg and of diastolic values (%D) > 95 mmHg. With echocardiography we measured left ventricular mass index (LVMI: Devereux) and with pulsed Doppler peak of early (E) and late (A) ventricular filling and the ration A/E. We found the same amount of correlations between ABPM and echocardiographic parameters as other authors. [table: see text] The study of LVMI found a difference between groups when MD were > 140/90 (*) and A was significantly greater in patients with MSD > 140 (*). LVMI was greater in patients with MDD > 80 (*) and A was greater in patients with MSN > 120 (*). Predictive value of MSD > 140: 53% specificity: 79%. Predictive value of MSN > 120: 80% specificity: 45.8%. We concluded that the correlations between ABPM and echocardiographic disturbances are not very strong, but significant. If the predictive value of MSF is low, his specificity is rather high and conversely MSN has a good predictive value for selection of hypertrophic patients.