[The curious case of a cardiac mass : A case report]. / Un curieux cas de masse cardiaque : à propos d'un cas.

BACKGROUND: Retained foreign bodies are dreadful events associated with invasive procedures. Their occurrence implicate physical complications as well as serious professional and medico-legal consequences. Cases of retained surgical items, in the pericardial space, following cardiothoracic surgery are rare and their management is delicate as the risks of their removal must be thoroughly weighed against the complications of leaving them inside the chest. CASE PRESENTATION: We report the case of a retained foreign body, discovered in an asymptomatic patient, on a routine medical check-up, 4 years after cardiac surgery. CONCLUSIONS: Clinical and paraclinical manifestations of retained surgical foreign bodies are nonspecific. The progress of cardiac imaging means makes it possible to identify these rare foreign bodies with greater precision, and allows, with extreme caution, to monitor patients who are perfectly asymptomatic and who are reluctant to undergo surgery.

Gemcitabine-Related Atrial Fibrillation: A Case Report and Review of the Literature.

INTRODUCTION: Gemcitabine is a commonly used antimetabolite that has been effective in a broad spec- trum of tumors so far. The main grade three and four known toxicity of this drug is myelosuppres- sion. Cardiac adverse events have been rarely reported and gemcitabine-induced Atrial-Fibrillation (AF) has been described in only five previous cases so far. Here we report the 6th case of gemc- itabine-related AF. CASE PRESENTATION: A 68-year-old man diagnosed with metastatic nasopharyngeal cancer was referred to our oncology department. He started first-line chemotherapy with gemcitabine and cisplatin. He presented poorly tolerated atrial fibrillation related to gemcitabine infusion that lasted for six days. The treatment was then withdrawn, and the patient received the best supportive care. CONCLUSION: We conclude that medical oncologists and cardiologists should be aware of such toxicities of gemc- itabine, especially in the elderly who seem to be at a higher risk of such adverse events and which may dictate discontinuation of the drug.

A rare combination of cardiac and pulmonary cyst and review of the literature.

Hydatid disease remains an important public health problem in endemic areas. We report a rare case of intramyocardial hydatid cyst of the right atrium along with a pulmonary hydatid cyst in a 16-year-old girl who was admitted to our hospital because of chest pain with recurrent episodes of fainting. One-stage surgery by median sternotomy under cardiopulmonary bypass was performed with excision of the hydatid cyst in the right atrium followed by the removal of the pulmonary hydatid cyst in the same session. Her postoperative recovery was uneventful. Based on this case, we emphasize, the rare combination of cardiac and pulmonary hydatid cyst. Another aspect that makes this case interesting is the location of the hydatid cyst at the right atrium, which is very rare. To the best of our knowledge, our case is the first to describe the combination of a hydatid cyst of the right atrium and the lung.

Brucella Prosthetic Valve Endocarditis: A Systematic Review.

OBJECTIVE: Brucella prosthetic valve endocarditis is a rare but a life-threatening complication of brucellosis. It remains a diagnostic challenge. Optimal treatment of Brucella prosthetic valve endocarditis is debated. Available data is limited to case reports or small case series. The purpose of this study was to systematically review all published cases of Brucella prosthetic valve endocarditis in the literature. METHOD: A systematic review of PubMed database, Google, Google Scholar, and Scopus (From January 1974 to the present) for studies providing epidemiological, clinical and microbiological data as well as data on treatment and outcomes of Brucella prosthetic valve endocarditis was performed. RESULTS: A total of 51 reported cases were reviewed. Brucella melitensis (45%) and Brucella abortus (11.7%) were the most frequently isolated species. Most common type of prosthesis valve was mechanical prothesis (84.3%) and ten patients had double valve prosthesis (19.6%). Fever and dyspnea were present in 100% and 37.2% of the cases, respectively. The diagnosis was set with echocardiographic finding in 30 cases (93.7%), which revealed vegetation in 27 cases (84.3%). Most used antibiotics were rifampicin, doxycycline and aminoglycoside or cotrimoxazole. No deaths were noted in patients treated by combined medical and surgical treatment, but mortality was noted in 27.7% of the cases treated by antibiotics alone (p = 0.006). CONCLUSION: This systematic review highlights diagnostic challenges and demonstrates that surgery improved outcome by reducing mortality in patients treated with the combined surgical and medical treatment option. Brucellosis should be considered in the differential diagnosis of prosthetic valve endocarditis in patients residing in or traveling to areas of endemicity.

The Association of IL-6, TNFα and CRP Gene Polymorphisms with Coronary Artery Disease in a Tunisian Population: A Case-Control study.

Coronary artery disease is an inflammatory disease. Systemic markers of inflammation such as Interleukin-6, Tumor Necrosis Factor alpha and C-reactive protein have previously been shown to be associated with increased risk of cardiovascular events. The aim of the present study is to assess the role of variants in the IL-6 (- 174 G/C), TNFα (- 308 A/G) and CRP (+ 1059G/C) genes as susceptibility markers for CAD in a Tunisian population. The investigation was conducted as a case-control study involving 204 patients and 400 age-gender matched controls. Genotyping was performed using polymerase chain reaction and restriction fragment length polymorphism analysis. There are significant differences between CAD patients and the control group with regard to BMI (p < 10-3) and family history of CAD (p < 10-3). The CAD patients are more likely to have a history of smoking (p < 10-3), have a higher value of TC (p = 0.003), LDLc (p = 0.016), hs-CRP (p = 0.01), IL6 (p < 10-3) and TNFα (p = 0.038). Our analysis showed significant differences between cases and controls in genotypic distribution of IL6-174CC (p = 0.003; OR = 7.71 CI (1.58-37.56)), TNFα - 308 AA (p = 0.004; OR = 2.95 (1.57-5.51)) and CRP + 1059 CC (p < 10-3; OR = 5.40 (2.30-12.68)). However, we failed to find an association between the different genotypes and the inflammatory markers levels. Our results suggest that the presence of IL-6 (- 174 G/C), TNFα (-308 A/G) and CRP (+ 1059G/C) polymorphisms, may be considered to be a risk factor for CAD in Tunisian population.

The Predictive Value of 2D Myocardial Strain for Epirubicin-Induced Cardiotoxicity.

INTRODUCTION: Although epirubicin has significantly improved outcome in breast cancer (BC) patients, it is responsible for myocardial dysfunction that affects patients' quality of life. The use of 2D global longitudinal strain (GLS) has been reported to detect early myocardial dysfunction. The aim of this study was to evaluate how GLS changes can predict cardiotoxicity. METHODS: We conducted a prospective study from March 2018 to March 2020 on 66 patients with no cardiovascular risk factors, who presented with BC and received epirubicin. We measured left ventricular ejection fraction (LVEF) and GLS before chemotherapy, at three months (T3), and at 12 months (T12) from the last epirubicin infusion. Chemotherapy-Related-Cardiac-Dysfunction (CTRCD) was defined as a decrease of 10% in LVEF to a value below 53% according to ASE and EACI 2014 expert consensus. RESULTS: The mean age at diagnosis was 47 ± 9 years old. At baseline, median LVEF was 70% and median GLS was -21%. Shortly after chemotherapy completion, two patients presented with symptomatic heart failure while asymptomatic CTRCD was revealed in three other patients at T12. Three months after the last epirubicin infusion, median LVEF was 65%, median GLS was -19%, and median GLS variation was 5%. However, in patients who presented with subsequent CTRCD, median GLS at T3 was -16% and median GLS variation was 19% (p=0.002 and p < 0.001, respectively, when compared to patients who did not develop cardiotoxicity). Persistent GLS decrease at T3 was an independent predictor of CTRCD at T12. Age and left-sided thoracic irradiation did not increase the risk of cardiotoxicity in our study while the cumulative dose of epirubicin significantly affected cardiologic findings (p=0.001). CONCLUSION: This was the first North African study that assesses the value of measuring GLS to early detect cardiotoxicity. Patients whose GLS remained decreased after 3 months from anthracyclines-base chemotherapy had an increased risk for developing subsequent CTRCD. Further studies with larger sample size are warranted to identify the best cardioprotective molecules to be initiated in these patients before LVEF declines.

Multimodality imaging assessment of a caseous calcification of the mitral valve annulus.

Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

Fatal postpartal dissection of all coronary arteries in an in vitro-fertilized woman.

Myocardial infarction complicates approximately 1 in 10,000 pregnancies [1]. Coronary artery dissection is the leading cause of pregnancy-related myocardial infarction during the postpartum period. Proposed etiologies include altered endocrine status, hemodynamic stress, eosinophilic inflammatory infiltrate, and disruption of vasa vasorum. Definitive diagnosis is made by coronary angiography. Treatment has not been well defined. Strategies include medical management, stenting, and coronary artery bypass grafting. Here, we report the postpartal dissection of all 3 coronary arteries and of the left main coronary in an in vitro-fertilized, 40-year-old woman who, after giving birth to a newborn by cesarean section, presented with myocardial infarction and required urgent coronary artery bypass surgery. Spontaneous coronary dissection that predominantly affects young women is rare and is often dramatic. One-third of the cases occur during pregnancy or in the postpartum period. Our case report is unique; postpartum coronary artery dissection in a patient of any age that was fertilized in vitro is very rare.

[Overview on the management of vasovagal syncope]. / Mise au point sur la prise en charge de la syncope vasovagale.

BACKGROUND: Vasovagal syncope (VVS) is the most common type of syncope. Despite its benignity, quality of life may be severely affected in a significant proportion of highly symptomatic patients. AIM: To review achral knowledgement concerning vasovagal syncope, to assess the utility of diagnostic investigation and report the updat therapeutic management. METHODS: An electronic search of the relevant literature was carried out using medline. Key words used for the final search were "Vasovagal syncope" "pathophysiology" "diagnosis" "tilt-table testing", "imlantableloop recoder", "treatment", "tilt training", isometric muscle tensing", "cardic pacing". RESULTS: A typical history of VVS is usually sufficient to make the diagnosis without any additional testing. Further testing is required when the diagnosis remains uncertain. Approaches to treatment are largely empirical and this is due to our lack of understanding of the pathophysiology. The management of VVS is often limited to reassuring and advising how to avoid predisposing factors with behaviour modification. For patients with recurrent episodes of syncope and premonitory symptoms, a conservative nondrug approach such as isometric muscle tensing should be considered. Tilt training can also be considered first-line therapy in motivated patients. Nevertheless, if patients still experience sudden recurrent and unpredictable episodes of syncope, a more aggressive treatment strategy is required with need of a prophylactic pharmacologic therapy. Various forms of medical treatment have been proposed but there are limited data from randomized controlled trials to support their effectiveness. The role of cardiac pacing is controversial and its indication should be restricted to patients over the age of 40 with severe recurrent syncope that is refractory to other therapies and in whom episodes include a substantial bradycardic component.