Prevalence and predictors of white-coat hypertension in a large database of ambulatory blood pressure monitoring.

The objective of this study was to determine both the prevalence of white-coat effect and white-coat hypertension (WCH) and which selected clinical variables were predictors of WCH. A total of 2462 patients underwent ambulatory blood pressure monitoring either in borderline hypertension (group 1) or for assessment of antihypertensive treatment (group 2) or for hypotension (group 3). In the overall population 33.0% of patients showed WCH, 32.8% in group 1 and 37.0% in group 2. In multivariate analysis, sex and grade of hypertension were independent predictors of WCH in groups 1 and 2.

[Takayasu's arteritis revealed by aortic regurgitation with ascending aortic aneurysm (About 2 cases)]. / Maladie de Takayasu révélée par une fuite aortique massive associée à un anévrisme de l'aorte ascendante (A propos de deux cas opérés).

Aortic regurgitation caused by non-specific aortitis is relatively rare, and is now considered as an important risk factor related to mortality. Aortic valve replacement surgery is the only curative treatment. Aneurismal dilatation of the ascending thoracic aorta associated with aortic regurgitation is a rare involvement in Takayasu, there are many difficult problems in surgical treatment of this lesion, because of its inflammatory nature, so steroid therapy before and after surgery is therefore vital. We report the cases of tow young Moroccans women (32-35 years-old) with an ascending aortic aneurism associated to aortic insufficiency. The subsequent evaluation of the entire aorta, demonstrated the presence of multiple steno-occlusive lesions. Aortic valve replacement was performed associated with graft replacement of the ascending aorta without coronary artery reimplantation. Histopathological examination of the ascending aorta and aortic valve, showed findings in favour Takayasu's arteritis.

[Evaluation of the vagal activity by the Deep-Breathing test]. / Evaluation de l'activité vagale par le test de la respiration profonde (Deep-Breathing).

OBJECTIVE: The Deep-Breathing (DB) test is of major importance in the evaluation of the vagal response (VR). We applied this test to assess the VR in a group of subjects with functional (neurological, cardiovascular or digestive) symptoms unexplained by standard cardiac examination and to compare it with the VR measured in a group of healthy controls. PATIENTS AND METHODS: The following groups were considered: a C-Group of healthy controls (n=50), and three groups each consisting of 50 symptomatic patients (S1, S2, S3). Subjects in the S1-Group had a postural orthostatic tachycardia syndrome (POTS), while members of the S2-Group had arterial hypertension, and members of S3-Group had neither POTS nor arterial hypertension. The VR was expressed as a percentage variation of RR intervals 100x[(RR(max)-RR(min))/RR(min)], and was correlated with age and sex in the C-Group before any comparison. RESULTS: In controls the VR was 31.0%+/-8.2. It was negatively correlated with age (r=-0.42, p=0.003) and there was no significant difference between males (31.2%+/-5.7) and females (30.9%+/-9.0) (p=0.12). Compared to the C-Group, the VR was 51.6%+/-20.4 in the S1-Group (p<0.001), 26.9%+/-11.3 in the S2-Group (p<0.001), and 47.2%+/-22.7 in the S3-Group (p<0.001). CONCLUSION: The VR was independent of sex but was negatively correlated with age. In comparison with healthy controls, it was significantly increased in the patients with POTS and significantly decreased in hypertensives.

[Left main coronary artery angioplasty: report of five cases illustrating the current indications]. / Angioplastie du tronc commun: a propos de cinq cas illustrant les indications actuelles.

OBJECTIVES: The purpose of our study is to illustrate by five original observations the various situations where the stenting of the left main coronary artery can be proposed in alternative to aortocoronary bridging with encouraging results in short- and long-term. MATERIALS AND METHODS: We report a retrospective study relating to five cases with left main disease treated by stenting between 1996 and 2002 at our institution. In two cases the left main stem was unprotected. In two other cases, the left main trunk was protected. And the last case was an emergency stenting for an iatrogenic dissection of the left main coronary artery. RESULTS: The stenting was carried out successfully among the five patients without major in-hospital complication. During the follow-up of 29 months at mean, no death was deplored, and no target lesion revascularization was required on the left main coronary artery (with a left main trunk permeable on three coronarographic controls). CONCLUSIONS: In the light of these results, and basing on the published data, we conclude that stenting for the left main coronary disease may be a safe and effective alternative to coronary artery bypass surgery in particular cases among "selected" patients (refusal or surgical contraindication, protected left main coronary artery, spontaneous or iatrogenic acute occlusion of the left main coronary artery).

[Percutaneous mitral commissurotomy and Lutembacher syndrome]. / Commissurotomie mitrale percutanée et syndrome de Lutembacher.

INTRODUCTION: Lutembacher syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. This condition is usually treated surgically by mitral valve operation with concomitant closure of the atrial septal defect. MATERIALS AND METHODS: Between 1993 and 2003, 4 patients with congenital Lutembacher syndrome had percutaneous mitral commissurotomy without closure of the atrial septal defect at our institution. The 4 patients were very symptomatic with right-sided heart failure signs and NYHA functional class III-IV. RESULTS: The procedure was carried out successfully for the four patients. Mitral valve area increased from 0.87 to 1.97 cm2 at mean; left atrial pressure decreased from 28.2 to 12.7 mmHg and the mean valve mitral gradient was reduced from 15.5 to 3.9 mmHg. Functional and clinical improvement was observed in all the cases. During a mean follow up of 55 +/- 29 months, our 4 patients remain pauci symptomatic under medical treatment. CONCLUSION: The percutaneous treatment of the Lutembacher syndrome is currently a possible alternative to the surgery among patients having an anatomy favourable to the procedure.

[Autonomic profile of patients with migraine]. / Profil autonomique des patients migraineux.

OBJECT: Dysfunction of autonomic nervous system (ANS) is implicated in the genesis and persistence of migraine. The objective of this study was to compare autonomic nervous system (ANS) profile of migraineurs during headache-free periods to a group of normal subjects based on cardio-vascular reactivity. METHODS: Patients with migraine according to the criteria of IHS 2004 were selected for the study. After a 30 min resting blood pressure (BP), the following standard tests were performed: deep-breathing (DB), hand grip (HG) of 15 s and 3 min, valsalva maneuver, echo stress, (ES) and tilt test (TT). Results were compared to 44 normal subjects, age similar, 37 female, (84.1%) using the Student test, with P < 0.005 as significant. RESULTS: Thirty-two patients (27 female (84.38%), 16-51 years, mean 40.41 +/- 7.8) were studied. Twenty-two patients (69%) had systolic blood pressure below 94 mmHg and 25 patients (78%) had diastolic blood pressure below 60 mmHg. Compared to normal, migraineurs exhibited a significantly higher vagal response (P < 0.001) and a significantly lower alpha sympathetic response, central by using ES as well as peripheral by using HG of 3 min (P < 0.001). CONCLUSIONS: Autonomic cardiovascular reactivity of patients with migraine showed a vagal hyperactivity and a deficiency of the alpha sympathetic system. This leads to further studies with new therapeutical approaches.

[Q fever: a rare cause of endocarditis]. / Fièvre Q: une cause rare d'endocardite A propos d'un cas.

Coxiella Burnetii endocarditis is very rare. It is the main complication of the chronic form of Q fever. Blood cultures are negative and clinical presentation very variable and diagnosis is essentially based on indirect immunofluorescence serum analysis. The authors report the case of a 19 year old patient with a history of rheumatic aortic regurgitation admitted for an episode of left ventricular failure in a context of long-term pyrexia without valvular vegetations or mutilation. The antiphase I Ig G antibody levels were significant. Treatment with doxycycline and fluoroquinolone was initiated. The clinical improvement was spectacular. Three months later, the patient underwent aortic valve replacement and histological examination of the valve showed subacute endocarditis on chronically fibrotic valvular disease. This is an interesting case by its rarity and its diagnostic and therapeutic problems.

[Infectious endocarditis of the right heart. Apropos of 10 cases]. / L'endocardite infectieuse du coeur droit. A propos de 10 observations.

Ten cases of right-sided infective endocarditis (IE) were recorded in a retrospective study over a 5 year period (1984-88). In 8 cases, IE complicated known congenital heart disease. One patient was followed up for rhumatic valvular disease and in the remaining case, IE seemed to have occurred on a normal valve. The inclusion criteria were based on the clinical signs: prolonged pyrexia, the finding of a new murmur or a change on cardiac auscultation, and eventually, the occurrence of a complication (7 cases). The commonest complications were right ventricular failure and pulmonary embolism. A portal of entry was found in 5 cases: dental infection in 3 cases, osteomyelitis in 1 case and an abscess on the right leg in 1 case. Blood cultures were positive in 5 cases and grew a staphylococcus aureus on each occasion. Two-dimensional echocardiography showed vegetations in 9 cases. The short-term outcome was satisfactory. There were no fatalities and 5 patients underwent surgery.

[Malignant non-Hodgkin's lymphoma in the superior vena cava and the right ventricle. A case report]. / Localisation cave supérieure et ventriculaire droite d'un lymphome malin non hodgkinien. A propos d'une observation.

A 39-year old patient presented with small, sudden hemoptyses and a diagnosis of pulmonary tuberculosis was made on radiographic pleural and parenchymatous lesions but without bacteriological confirmation. Two years later, the patient was admitted to hospital following severe hemoptysis. Echocardiography revealed the presence of a tumour in the right ventricular outflow tract. At surgery, nodules were also resected from the superior vena cava. Histological examination of the surgical specimens suggested that the tumour was an angiosarcoma. Six months later, the patient returned complaining of a painful swelling in the left iliac fossa. Immuno-histochemical analysis of the cardiac and abdominal tumours finally concluded that it was in fact a malignant non-Hodgkinian lymphoma.

[Capillary hemangioma of the left ventricle. A case report and review of the literature]. / Hémangiome capillaire du ventricule gauche. A propos d'un cas et revue de la littérature.

The authors report a case of isolated left ventricular capillary haemangioma, diagnosed after chest X-ray during a routine medical check-up showed a deformation of the left heart border. Echocardiography showed a solid well circumscribed tumour. Its vascular origin was confirmed at coronary angiography. Myocardial biopsy performed after left thoracotomy confirmed the histological diagnosis. The authors review the medical literature of this condition in the light of this rare finding.

[Traumatic rupture of the right anterior sinus of Valsalva into the right ventricle combined with aortic regurgitation]. / Rupture traumatique du sinus de Valsalva antéro-droit dans le ventricule droit, associée à une insuffisance aortique.

We report the case of a 14-year old boy who was stabbed with a knife and sustained a chest wound responsible for clinical tamponade. Surgery was performed as an extreme emergency, so that lesions could not be assessed preoperatively. During the operation, beside the pericardial blood collection a wound of the pulmonary infundibulum was discovered and sutured (closed heart surgery). One year later the patient was readmitted for global heart failure. Auscultation of the heart revealed a continuous left latero-sternal murmur. Two-dimensional echocardiography showed discontinuity between the right anterior sinus of Valsalva and the right ventricular outflow tract. Contrast echocardiography displayed a negative jet image in the right ventricular outflow tract. At that level, pulsed doppler ultrasound recorded continuous turbulence as well as diastolic turbulence in the left ventricular outflow tract. Tiered oxymetry showed a left-to-right shunt in the right ventricle with a pulmonary/systemic flow ratio of 1.9. The diagnosis was confirmed by angiography which demonstrated a fistula between the right anterior sinus of Valsalva and the right ventricular outflow tract, and aortic regurgitation. In a second operation, performed under extracorporeal circulation, the traumatic lesions were repaired, and the patient thereafter recovered. This unusual case highlights the value of combined two-dimensional echocardiography, pulsed doppler ultrasound and contrast echocardiography in the diagnosis of traumatic ventriculo-aortic lesions.

[Hemangio-endotheliosarcoma of the right atrium]. / Hémangio-endothéliosarcome de l'oreillette droite.

In reporting a case of haemangiosarcoma of the right atrium the authors emphasize the problems encountered in the diagnosis of primary tumours of the heart. The patient was a 50-year old woman who complained of digestive disorders and palpitations. Physical examination showed signs of right heart failure associated with a systolic murmur on the right side of the sternum. ECG gave normal results. Echocardiography displayed a pouch with liquid ultrastructure communicating with the right atrium. Angiography confirmed the presence of a cavity with irregular borders communicating with the right atrium. Coronary arteriography showed an abnormal disorderly distribution of the right coronary artery branches with newly formed vessels extending toward the tumour. At exploratory thoracotomy a large liquid tumour was found which bled at the slightest touch and was attached to the mediastinum and the right pericardium. The pleura and the lung contained several nodules of the same venous colour as the mother tumour. Extemporaneous biopsy and pathological analysis were in favour of a haemangiosarcoma. The patient died a few days after the thoracotomy.

[Tumor in the right cardiac chambers. Regression after antitubercular treatment. Apropos of a case]. / Tumeur des cavités cardiaques droites. Régression après traitement antituberculeux. A propos d'un cas.

The authors report the case of a young patient with a tumour of the right atrium and right ventricular outflow tract without visceral complications but with multiple muscular and skin localisations. The diagnosis of tuberculosis was made on biopsy of a suppurating skin lesion. The diagnosis of tuberculosis was made on biopsy of a suppurating skin lesion. Anti-tuberculosis treatment resulted in regression of these tumours, especially the cardiac lesions, confirmed by transoesophageal echocardiography.

[Syphilitic aortitis and "accelerated" atherosclerosis]. / Aortite syphilitique et athérosclérose "accélérée".

The authors present the case of a 42 year old patient admitted for surgery of massive aortic regurgitation. Investigation of this patient who had no significant cardiovascular risk factors, showed diffuse and accelerated atherosclerosis (severe stenosis at the origin of both subclavian arteries at both superficial femoral arteries). Tertiary syphilis with neurological involvement and aortitis was confirmed by histological examination (peroperative biopsy of the aortic wall). This case is unusual due to the association of early atherosclerosis with tertiary syphilis and raises the question of the causality of syphilis in the generation of these atherosclerotic lesions.

[Pericardial hemolymphangioma. Apropos of a case]. / Hémolymphangiome péricardique. A propos d'une observation.

A case of pericardial hemolymphangioma revealed by palpitations is reported. X-ray films of the chest provided a diagnosis of mediastinal tumour. Full evaluation was performed using echocardiography, computerized tomography of the mediastinum, coronary arteriography and cardiac ventriculography. The tumour could be removed in toto. Pericardial hemolymphangioma is a rare benign vascular tumour. It is often discovered accidentally during examinations for non-suggestive cardiac functional disorders. The threat of compression or invasion of adjacent structures and that of hemopericardium by bleeding make surgical excision mandatory.

[Percutaneous dilatation with a balloon catheter in subaortic stenoses]. / La dilatation percutanée par cathéter à ballonnet des sténoses sous-aortiques.

Since 1987, percutaneous transluminal dilatation with a balloon catheter was performed in 4 patients with subaortic diaphragm. The patients' mean age was 13 years (range 6 to 22 years). Two of them were asymptomatic and all had mild to moderate aortic valve regurgitation. In all patients two-dimensional echocardiography showed the presence of sub-aortic stenosis. Following dilatation, 2D-echocardiography showed an image of membrane floating in the left ventricular outflow tract. The left ventricular systolic pressure fell from 194 +/- 24 to 147 +/- 16 mmHg and the intraventricular systolic gradient, from 92 +/- 21 to 31 +/- 3 mmHg. There were no changes in aortic regurgitation. No complication was observed.

[Myxoma of the right ventricle. Apropos of 2 cases]. / Myxomes du ventricule droit. A propos de 2 observations.

Two cases of primary cardiac tumour are reported. The first was that of a 16 year old girl investigated after the detection of a systolic murmur on routine examination. The clinical signs suggested a diagnosis of pulmonary stenosis. The second case was that of a 36 year old man admitted to hospital for right ventricular failure. Echocardiography revealed right ventricular tumours in both cases and also indicated their size, form, mobility and site of implantation. The outcome of the first case, a fibromyxoma, was favourable with no detectable recurrence after one year. In the second case, the patient unfortunately died of cardiogenic shock in the immediate preoperative period. These two cases emphasise the value of echocardiography in the diagnosis of isolated right ventricular tumours, especially considering the difficulty of clinical diagnosis and the risks of angiocardiography.

[An experience of lipoprotein (a) dosage in a Moroccan population of 184 subjects]. / Expérience du dosage de la lipoprotéine (a) dans une population marocaine de 184 sujets.

One hundred and eighty-four patients underwent complete lipid analysis (total cholesterol, HDL and LDL cholesterol, triglycerides, apolipoproteins A1 and B, lipoprotein (a)) and coronary angiography, in order to evaluate the discriminant value of the lipoprotein (a). Subjects with non-significant coronary stenoses (< 50% of the lumen) were used as a control group (n = 84). The others were considered to be pathological. The total cholesterol, HDL cholesterol and triglycerides were measured by an enzymatic colorimetric method. The LDL cholesterol was calculated by Friedewald's formula. The apolipoprotein A1 and B were measured by immunoturbidimetry and the lipoprotein (a) by an Elisa. The results showed a relationship between the different lipid levels, especially between high lipoprotein (a), and the severity of the coronary disease. A quantitative and qualitative study showed no significant influence of the other risk factors on the mean lipoprotein (a) level. Gender and age had no influence. Therefore, the higher the lipoprotein (a) level, the greater was the coronary risk, independently of the other associated risk factors.

[Angioplasty and endoprosthesis of the left coronary artery. Report of a case]. / Angioplastie et endoprothèse du tronc coronaire gauche. A propos d'un cas.

The authors report the case of a 70 year old woman followed up in our Department for ischaemic heart disease since 1991 and admitted to the Intensive Care Unit in November 1996 for unstable angina. Coronary angiography showed significant stenosis of the left main coronary artery, a severe stenosis of the LAD and occlusion of the right coronary artery. Angioplasty of the middle segment of the LAD and left main coronary arteries with implantation of a stent was performed because of resistance to medical therapy and a contra-indication to surgery. Four months later, recurrent anginal pain led to a repeat angioplasty of the LAD with a satisfactory immediate result. The initial procedure on the left main coronary artery was successful and follow up was uncomplicated.

[Percutaneous transluminal valvuloplasty of pulmonary stenoses. Apropos of 35 cases]. / Valvuloplastie transluminale percutanée des sténoses pulmonaires. A propos de 35 cas.

Thirty-five patients with moderate or severe valvular pulmonary stenosis underwent percutaneous transluminal valvuloplasty (PTV). The average age of the patients was 12 years (range 4 to 34 years). Sixty per cent were under the age of 10, 20 p. 100 were between 10 and 17 years old and 20 p. 100 between 18 and 34 years old. Systolic right ventricular pressures were greater than the pressures in the systemic circulation in 22 cases. The right ventricular-pulmonary artery pressure gradient was greater than 50 mmHg in 29 patients and less than or equal to 50 mmHg in the other 6 patients. The diameter of the balloon of the dilation catheter varied from 12 to 20 mm in 31 PTV; in the other 4 cases two dilating catheters were used simultaneously to dilate the pulmonary valves. The tolerance of PTV was generally good and the results were satisfactory: right ventricular pressures (RVP) fell from 140 +/- 45 to 77 +/- 25 mmHg (p less than 0.001); the RV-PA pressure gradient fell from 82 +/- 40 to 32.4 +/- 15 mmHg (p less than 0.001) and the ratio of RVP to systemic pressure from 1.2 +/- 0.4 to 0.65 +/- 0.2 (p less than 0.01). Clinical and haemodynamic reevaluation in 19 patients 4 to 16 months after PTV (mean 8.5 +/- 2 months) showed that RVP, RV-PA pressure gradients and RVP/systemic pressure ratios had significantly decreased respectively from 78 +/- 30 to 52 +/- 14 mmHg (p less than 0.001), from 27.7 +/- 7.7 to 21.8 +/- 7.3 mmHg (p less than 0.02) and from 0.6 +/- 0.2 to 0.4 +/- 0.1 (p less than 0.001). Pulmonary valvuloplasty is well tolerated, safe and may reduce the number of patients requiring surgical valvotomy.