Cardiac magnetic resonance assessment of left ventricular dilatation in chronic severe left-sided regurgitations: comparison with standard echocardiography.

PURPOSE: The purpose of this study was to investigate the potential additional value of cardiac magnetic resonance (CMR) in the assessment of left ventricular (LV) dilatation and dysfunction by comparison to standard echocardiography in patients with chronic left-sided valvular regurgitation. MATERIALS AND METHODS: We prospectively enrolled patients with chronic severe mitral regurgitation (MR) or aortic regurgitation (AR). They underwent standard echocardiography and CMR using aortic flow and LV-function sequences. LV dilatation or dysfunction was assessed with each technique, based on thresholds used for surgery indication. Reference regurgitation severity was defined following previously reported CMR-based regurgitant volume thresholds. RESULTS: A total of 71 patients with chronic severe MR (n=44) or severe AR (n=27) were prospectively included. There were 60 men and 11 women with a mean age of 61±14 (SD) years (range: 18-83 years). CMR-based regurgitation severity was significantly greater in the LV dysfunction group when assessed with CMR (MR, P=0.011; AR, P=0.006) whereas it was not different when LV dysfunction was assessed using standard echocardiography. Among standard echocardiography and CMR volumetric indices, CMR-derived end-diastolic volume showed the best ability to predict regurgitation severity (area under the curve [AUC]=0.78 for MR; AUC=0.91 for AR). Diagnostic thresholds identified on receiver operating characteristics-curve analysis were lower than those of current European recommendations and closer to North-American guidelines. CONCLUSION: CMR assessment of LV end-diastolic volume in chronic severe left-sided regurgitations is more reliably associated with CMR-based regurgitant volume by comparison with standard echocardiography diameter. CMR may provide useful evaluation before surgery decision for severe asymptomatic regurgitations.

Lactobacillus reuteri and Escherichia coli in the human gut microbiota may predict weight gain associated with vancomycin treatment.

BACKGROUND: Antibiotics, used for 60 years to promote weight gain in animals, have been linked to obesity in adults and in children when administered during early infancy. Lactobacillus reuteri has been linked to obesity and weight gain in children affected with Kwashiorkor using ready-to-use therapeutic food. In contrast, Escherichia coli has been linked with the absence of obesity. Both of these bacteria are resistant to vancomycin. OBJECTIVES AND METHODS: We assessed vancomycin-associated weight and gut microbiota changes, and tested whether bacterial species previously linked with body mass index (BMI) predict weight gain at 1 year. All endocarditis patients treated with vancomycin or amoxicillin in our center were included from January 2008 to December 2010. Bacteroidetes, Firmicutes, Lactobacillus and Methanobrevibacter smithii were quantified using real-time PCR on samples obtained during the 4-6 weeks antibiotic regimen. L. reuteri, L. plantarum, L. rhamnosus, Bifidobacterium animalis and E. coli were quantified on stool samples obtained during the first week of antibiotics. RESULTS: Of the193 patients included in the study, 102 were treated with vancomycin and 91 with amoxicillin. Vancomycin was associated with a 10% BMI increase (odds ratio (OR) 14.1; 95% confidence interval (CI; 1.03-194); P=0.047) and acquired obesity (4/41 versus 0/56, P=0.01). In patients treated with vancomycin, Firmicutes, Bacteroidetes and Lactobacillus increased, whereas M. smithii decreased (P<0.05). The absence of E. coli was an independent predictor of weight gain (OR=10.7; 95% CI (1.4-82.0); P=0.02). Strikingly, a patient with an 18% BMI increase showed a dramatic increase of L. reuteri but no increase of E. coli. CONCLUSION: The acquired obesity observed in patients treated with vancomycin may be related to a modulation of the gut microbiota rather than a direct antibiotic effect. L. reuteri, which is resistant to vancomycin and produces broad bacteriocins, may have an instrumental role in this effect.

Cardiac MRI in the diagnosis of complications of myocardial infarction.

The improvement in revascularization techniques and medicine treatment during infarction has substantially reduced mortality during the acute phase of this condition. Since the advent of kinetic sequences and the concomitant development of gadolinium chelates and delayed enhancement sequences, cardiac MRI has become the second-line reference examination for ischemic heart disease. The technique of delayed enhancement with the inversion recovery sequence performed after injection has been validated for numerous indications in ischemic disease. Delayed enhancement sequences make it possible in particular to look for "no-reflow" areas (microvascular obstructions), to quantify the infarction area, and to assess prognosis. MRI also allows us to define the area at risk, that is, the area with edema, and to look for and assess the mechanical complications of the infarction. The aim of this review is to summarize current knowledge about: the pharmacokinetic principles that regulate myocardial enhancement; the different sequences available to acquire delayed enhancement images, and; the value of cardiac MRI in the diagnosis of complications of myocardial infarction.

Clinical characteristics and outcome of infective endocarditis in adults with bicuspid aortic valves: a multicentre observational study.

OBJECTIVE: To analyse characteristics and outcomes of infective endocarditis (IE) on bicuspid aortic valves (BAV) and to compare the risk of death according to the presence or absence of BAV. DESIGN: 5-year observational study. SETTING: Population of 856 patients with definite IE according to the Duke criteria from two tertiary centres (Amiens and Marseille, France). PATIENTS: 310 consecutive patients with definite native aortic valve IE enrolled between 1991 and 2007. INTERVENTIONS: Patients underwent transthoracic and transoesophageal echocardiography during hospitalisation. Surgery was performed on a case-by-case basis according to conventional guidelines. MAIN OUTCOME MEASURES: In-hospital mortality and 5-year overall mortality. RESULTS: Patients with BAV IE (n=50, 16%) were younger, had fewer comorbidities and a higher frequency of aortic perivalvular abscess (50%). Presence of BAV (OR 3.79 (1.97-7.28); p<0.001) was independently predictive of abscess formation. Early surgery was performed in 36 BAV patients (72%) with a peri-operative mortality of 8.3%, comparable to that of patients with tricuspid aortic valve IE (p=0.89). BAV was not independently predictive of in-hospital mortality (OR 0.89 (0.28-2.85); p=0.84) or 5-year survival (HR 0.71 (0.37-1.36); p=0.30). Age, comorbidities, heart failure, Staphylococcus aureus and uncontrolled infection were associated with increased 5-year mortality in BAV patients. CONCLUSION: BAV is frequent in adults with native aortic valve IE. Patients with BAV IE incur high risk of abscess formation and require early surgery in almost three-quarters of cases. IE is a severe complication in the setting of BAV and warrants prompt diagnosis and treatment.

Evaluation of the LightCycler SeptiFast test in the rapid etiologic diagnostic of infectious endocarditis.

The SeptiFast test (Roche Diagnostics) is a new commercial molecular technique that has emerged for the detection of bacteria in blood. We compared in this study the sensitivity of blood culture to a commercially available broad-range real-time polymerase chain reaction (PCR) assay for the detection in blood of 19 bacterial species and six fungal species (SeptiFast test, Roche Diagnostics) in 63 patients with infectious endocarditis (IE). The SeptiFast test is not more sensitive for organisms such as Streptococci, Enterococci, and Staphylococcus aureus (11/29 versus 12/29 for blood culture). It has detected less commonly coagulase-negative Staphylococci (0/15 versus 3/15, P = 0.2) and significantly fewer other microorganisms (0/6 versus 4/6, P = 0.03). However, bacteria were detected from three IE treated by antibiotics, with blood culture negative on admission. The SeptiFast test may be useful in cases of IE in patients treated with antibiotics before admission.

[Mitochondrial cardiomyopathy in an adult: a case history]. / Cardiomyopathie mitochondriale de l'adulte: à propos d'un cas.

We report an original case of mitochondrial cardiomyopathy discovered in a young woman during an episode of cardiac decompensation. The diagnosis was suspected from the echocardiographic appearances of granite-like heterogeneous hypertrophic cardiomyopathy. It was confirmed by endomyocardial biopsies. The clinical evolution was favourable with classical treatment. Mitochondrial cardiomyopathy is a rare cause of cardiomyopathy, generally observed in children, with multisystemic localisation. The pathophysiology and genetics are complex. Cardiac involvement is observed in 25% of cases, with the principal manifestation being hypertrophic cardiomyopathy. In the absence of any specific clinical or paraclinical signs, echocardiography and MRI are the techniques of choice for morphological evaluation. Diagnosis relies upon myocardial biopsy, which should be readily advocated in every unexplained case of cardiomyopathy in a young subject. The prognosis is poor and no specific treatment is available.

Diagnosis of Coxiella burnetii pericarditis using a systematic prescription kit in case of pericardial effusion.

Coxiella burnetii, regarded as a potential agent of pericarditis, wa found to be responsible for almost 5% of the cases of idiopathic pericardial effusion reported in this series. Diagnosis was aided by use of a systematic kit described in this paper.

[Update on infectious endocarditis]. / Données récentes sur l'endocardite infectieuse.

Although one of the oldest known cardiac disease, infectious endocarditis (IE) remains a subject of constant change from epidemiological, diagnostic and therapeutic points of view. In the epidemiological field, the main feature is the increasing incidence of IE due to streptococcus bovis. Representing a quarter of cases in France, this type of IE is particularly frequent in the elderly and underlying colonic disease should be investigated. In the diagnostic field, the progress of methods of microbiological identification has been considerable, especially in molecular (PCR) and histological diagnosis which are particularly useful in IE with negative blood cultures. From the prognostic point of view, the role of echocardiography has recently been emphasised not only for diagnosis but also for prognosis and for predicting the embolic risk. The longest vegetations (>10 or 15 mm) are associated with a greater risk not only of embolism but also in terms of prognosis. The recent recommendations of the French Society of Cardiology recall the main surgical indications in IE and include a new indication of echocardiography.

Prosthetic valve endocarditis: who needs surgery? A multicentre study of 104 cases.

OBJECTIVES: To identify the prognostic markers of a bad outcome in a large population of 104 patients with prosthetic valve endocarditis (PVE), and to study the influence of medical versus surgical strategy on outcome in PVE and thus to identify patients for whom surgery may be beneficial. DESIGN: Multicentre study. METHODS AND RESULTS: Among 104 patients, 22 (21%) died in hospital. Factors associated with in-hospital death were severe co-morbidity (6% of survivors v 41% of those who died, p = 0.05), renal failure (28% v 45%, p = 0.05), moderate to severe regurgitation (22% v 54%, p = 0.006), staphylococcal infection (16% v 54%, p = 0.001), severe heart failure (22% v 64%, p = 0.001), and occurrence of any complication (60% v 90%, p = 0.05). By multivariate analysis, severe heart failure (odds ratio 5.5) and Staphylococcus aureus infection (odds ratio 6.1) were the only independent predictors of in-hospital death. Among 82 in-hospital survivors, 21 (26%) died during a 32 month follow up. A Cox proportional hazards model identified early PVE, co-morbidity, severe heart failure, staphylococcus infection, and new prosthetic dehiscence as independent predictors of long term mortality. Mortality was not significantly different between surgical and non-surgical patients (17% v 25%, respectively, not significant). However, both in-hospital and long term mortality were reduced by a surgical approach in high risk subgroups of patients with staphylococcal PVE and complicated PVE. CONCLUSIONS: Firstly, PVE not only carries a high in-hospital mortality risk but also is associated with high long term mortality and needs close follow up after the initial episode. Secondly, congestive heart failure, early PVE, staphylococcal infection, and complicated PVE are associated with a bad outcome. Thirdly, subgroups of patients could be identified for whom surgery is associated with a better outcome: patients with staphylococcal and complicated PVE. Early surgery is strongly recommended for these patients.

[Mitral regurgitation in infective endocarditis]. / Insuffisance mitrale d'origine endocarditique.

Endocarditis affecting the mitral valve is frequent and is associated with specific features. Mitral prolapse is the most frequent underlying disease and the mechanism of mitral regurgitation secondary to infective endocarditis is frequently complex and multiple. Echocardiography plays a key-role in both the diagnosis, the prognostic assessment and the choice of the best therapeutic option in patients with mitral valve endocarditis. Surgery is frequently necessary, and must be performed early in the course of the disease. Mitral valve repair is the best therapeutic option, when technically possible.

[Isolated non-compaction of the left ventricle]. / Non-compaction isolée du ventricule gauche.

Isolated non compaction of the left ventricle is a rare congenital cardiomyopathy linked to an arrest of normal myocardial embryogenesis. We report two cases of isolated non compaction of the left ventricle discovered by echocardiography in 2 males of 30 and 55 years. The first had progressively worsening cardiac insufficiency, the second was being followed for an unexplained cardiomyopathy. In both cases, the diagnosis was able to be confirmed by transthoracic echocardiography, supported by MRI data. Although present from birth, this condition can become apparent at various ages and is complicated by sudden death (principal cause of mortality), severe cardiac insufficiency, or thrombo-embolic accidents. The diagnosis of left ventricular non compaction should be considered when faced with unexplained cardiac insufficiency in the adult.

[Mitral insufficiency related to a spasm of the left anterior descending artery. A case report]. / Insuffisance mitrale due à un spasme de l'IVA. A propos d'un cas.

We report the case of a female patient of 76 years old admitted to our hospital for a pre-operative assessment of a symptomatic mitral regurgitation (MR) whose transthoracic echocardiography revealed only a trivial regurgitation. The occurrence during hospital stay of an acute pulmonary edema contemporary to the occurrence of a huge MR permitted to suspect the diagnosis of a paroxystic ischemic MR. Angiographic and hemodynamic evaluation revealed only a non-significant atheromateous plaque located in the distal LAD. The infusion of Methylergometrine triggered a severe spasm at the site of that plaque, associated with a huge MR visualized by TTE with restricted movements of both leaflets, responsible for an acute pulmonary edema occurring on the table of the catheterization laboratory. Recovery was quickly obtained after intravenous injection of Nitroglycerin, which removed the spasm and valvular regurgitation. The diagnosis of paroxystic ischemic mitral regurgitation was confirmed and a treatment based on high dosage of calcium-blocker was decided. After a follow-up of more than one year, the patient remains asymptomatic and the regurgitation has never occurred.

[Cardioversion by external electric shock for atrial fibrillation: does patient age affect immediate results?]. / Cardioversion par choc électrique externe de la fibrillation auriculaire: l'âge des patients affecte-t-il les résultats immédiats?

The restoration of sinus rhythm by external electric shock in patients with persistent atrial fibrillation is a well established treatment. However, in current practice this treatment is generally indicated less in the elderly subject although this attitude is not factual. The objective of this work was to evaluate the immediate results of cardioversion by external electric shock, comparing the success rates in four age groups: under 60 years, between 60 and 69 years, between 70 and 79 years, and over 80 years. This study was performed on 182 consecutive patients aged from 25 to 89 years: 35 patients aged less than 60 years, 52 patients aged from 60 to 69 years, 65 patients aged from 70 to 79 years, and 30 patients aged 80 years or over. The success rates were 91.4% before 60 years, 90.4% between 60 and 69 years, 90.8% between 70 and 79 years, and 83.3% after 80 years. There was no significant difference between the success rates in the four age groups (p = 0.68). Among the other factors analysed, only the duration of atrial fibrillation and the body mass index significantly influenced the results of external electric shock in this series. This work suggests that age does not significantly influence the immediate results of external electric shock. According to these data it does not appear justified to contra-indicate cardioversion by external electric shock on the sole criterion of age.

Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with that caused by other pathogens.

The aim of our study was to compare the clinical, echographic, and prognostic features of Streptococcus bovis (S. bovis) endocarditis with those caused by other streptococci and pathogens in a large sample of patients with definite endocarditis by Duke criteria, using transesophageal echocardiography. Two hundred six patients (149 men, mean age 57 +/- 15 years) with a diagnosis of infective endocarditis formed the study population. All patients underwent multiplane transesophageal echocardiography and blood cultures. Cerebral, thoracoabdominal computed tomographic scan was performed in almost all patients (95%). All patients with S. bovis endocarditis underwent colonoscopy. Incidence of S. bovis endocarditis in our sample was 19%. Patients with S. bovis endocarditis were older than other groups. Multiple valve involvement, native valves, and large vegetations (>10 mm) were more frequent in patients with S. bovis. There was a significantly higher occurrence of embolism in the S. bovis group. Splenic embolism and multiple embolisms were significantly more frequent in patients with S. bovis. Gastrointestinal lesions, anemia, and spondylitis were observed more frequently with S. bovis endocarditis. In addition to the requirement for gastrointestinal examination for S. bovis endocarditis, our study underlines the need for systematic screening for vertebral and splenic localizations, and suggests the use of early surgery to prevent the high risk of embolism in these patients.