Spontaneous calcific cerebral embolization revealing a calcified rheumatic mitral stenosis: a case report.

BACKGROUND: Cerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly iatrogenic secondary to heart or aorta catheterization. However, spontaneous cerebral calcified embolism in the case of calcified aortic valve is very rare and there are less than 10 case reports in the literature. And a more interesting fact is that such an event, in the context of calcified mitral valve disease, has never been reported, at least to our knowledge. We are reporting a case of spontaneous calcified cerebral embolism revealing a calcified rheumatic mitral valve stenosis. CASE PRESENTATION: We report a case of a 59 year-old Moroccan patient, with a history of rheumatic fever at the age of 14 and no history of recent cardiac intervention or aortic/carotid manipulation, who was admitted to the emergency department after a transient ischemic attack. Physical examination at admission found normal blood pressure of 124/79 mmHg and heart rate of 90 bpm. A 12-lead electrocardiogram showed an atrial fibrillation, no other anomalies. Unenhanced cerebral computed tomography imaging was performed, revealing calcified material inside both middle cerebral arteries. Transthoracic echocardiography was performed, showing severe mitral leaflets calcification with a severe mitral stenosis, probably due to rheumatic heart disease. Cervical arteries Duplex was normal. A vitamin K antagonist (acenocoumarol) was prescribed, targeting an international normalized ratio of 2-3 and mitral valve replacement surgery was performed using mechanical prosthesis. Short- and long-term health, with a 1-year follow-up, were good and the patient did not experience any stroke. CONCLUSION: Spontaneous calcified cerebral emboli secondary to mitral valve leaflet calcifications is an extremely rare condition. Replacement of the valve is the only option to prevent recurrent emboli and outcomes are still to be determined.

Cardiac tamponade: Better prognosis in association with pulmonary embolism: Case report.

The tamponade leads to an increase in intrapericardial pressure, which impairs the diastolic filling of the ventricles and reduces ejection. However, the association with pulmonary arterial hypertension, which in turn leads to an intracardiac hyper-pressure, constitutes a compensatory mechanism. We report the case of a 23 year old patient followed for anemia due to martial deficiency for 2 years, who consulted us with right heart failure evolving for 5 months, a hemoptoic cough and chest tightness. The entire workup revealed a pericardial and pleural tamponade of tuberculous origin associated with a pulmonary embolism evaluated at 15% according to the Qanadli score. After stabilization of her hemodynamic state, the patient was put on anti-bacillary and anticoagulant treatment with a good improvement of her cardiopulmonary state. She was discharged after 1 month (satisfactory check-up), regularly followed up in outpatient clinic with check-up of hemostasis and cardiac echography every 2 weeks. She was declared cured of her tuberculosis after 6 months of treatment. There was no recurrence after two years of follow-up. The combination of tamponade and pulmonary hypertension is synergistic in that it improves the patient's prognosis.

[Approach of Moroccan cardiologists to arterial hypertension]. / Les cardiologues marocains face à l'hypertension artérielle.

The authors conducted a survey among 300 cardiologists in order to evaluate their knowledge of HT. Most of the 200 cardiologists answering the survey considered that systolic HT was defined by a systolic blood pressure greater than 160 mmHg (75%). Only 14 cardiologists (7%), defined systolic HT as a blood pressure greater than 140 mmHg. 121 cardiologists (60.5%) defined diastolic HT as a pressure greater than 95 mmHg. 2/3 of cardiologists were not familiar with the conclusions of the JNCV for the detection, evaluation and treatment of HT. All cardiologists agreed that treatment of HT should start with single-agent therapy. In the case of insufficient control, 11% doubled the dose, 5% changed the drug in the same class, 53% changed therapeutic category and 30% prescribed two-agent therapy. Once BP was stabilized, one half of cardiologists reviewed their patients once every 3 months, and 22.5% reviewed their patients once every six months. These results demonstrate that cardiologists do not correctly follow the rules of management of HT recently defined by the various working parties. The authors propose a number of points to remedy some of the deficiencies revealed by this survey.

[Variations of blood pressure during the month of Ramadan]. / Variations tensionnelles au cours du mois de Ramadan.

The goal of this work is to study the consequences of the last on variations of the blood pressure (BP) in the course of 24 hours. From 1994 to 1997 we have selected 99 hypertensive patients and studied their BP profile. This study included 72 women and 27 men. Their age varies from 22 to 72 years (average 56.7 +/- 9 years). All these patients has an ambulatory blood pressure measurement (ABPM) before the fast and during Ramadan. Before Ramadan the period of the sleep goes from 10 pm +/- 1 h to 8 am +/- 1 h. During the month of Ramadan, the sleep lasts from 0 h +/- 1 to 9 am +/- 1 h. [table: see text] No statistically significant difference is noted between these 2 periods neither for the systolic BP (SBP) nor for the diastolic BP (DBP), for the BP of 24 hours, and the diurnal and nocturnal periods. We have then the compared the hourly average on 24 hours of the 99 patients. We observed that during the month of Ramadan the peak of the awakening is delayed by 2 hours and the nocturnal through is delayed by 1 hour. After this study, which is the first one to deal with variations of blood pressure during the fast of Ramadan we can confirm that in patients with essential hypertension without complications, the fast is well supported. The variations of BP are minimal and are related to the variations of the sleep, activity and eating pattern.

[Blood pressure determination and medical competence]. / Mesure de la pression artérielle et profil médical.

Hypertension diagnosis depends closely to the blood pressure measurement. The aim of this work is to show whether blood pressure measurement should be done by a beginner or a competent doctor. The blood pressure of 180 patients, (150 females, 30 males) was taken by two physicians. The patients' average age was 51 +/- 11. One of the two physicians was a cardiologist who took all the patients blood pressure. Others where six doctors in training, that is sixth' year students at the faculty of medicine. They took part in this study for a week. The procedure was that the cardiologist and one of the training doctors took the patient's blood pressure at the same time after 15 min rest. We have calculated the average systolic blood pressure and diastolic blood pressure of 720 measures. Then the difference between the cardiologist's measures and those of all the training doctors. After that we have analysed the difference between the average of 120 measures taken by one of the training doctors and the corresponding measurement of the specialist. We have then compared the difference of the 20 measures of every day taken by the training doctor and the ones taken by the specialist. The difference wasn't statistically significant either for the systolic blood pressure or the diastolic blood pressurement. We have studied the evolution of the average of the 20 measurements of every day during the whole week. So, we have noticed that the difference lowers from the first days to the sixth. In the end, we were interested in the last figure of each measurement of blood pressure. The training doctor often gave measurements up to 0 or 5 whereas the specialist gave precise measurements. We have concluded from this work that if experience is needed, the physician has to know the principals and the tricks of blood pressurement. Moreover, the blood pressure variations by "white coat" effect can't be explained by measurements techniques. This effect can be considered as psychic, interactions between doctors and patients.

[Heart failure and arterial hypertension disclosing amyloidosis]. / Insuffisance cardiaque et hypertension artérielle révélatrice d'une amylose.

Amyloidosis results from protein infiltration of the extracellular space of organs and tissues. Several amyloidosis proteins have been identified. Protein AL, (deriving from immunoglobulin light chain), protein AA and prealbumin are the most involved in this disease. When AL amyloidosis involves the heart, the illness is often terminal. Most clinical symptoms are heart failure and arrhythmia or block conduction. This case was characterised by the unusual combination of hypertension and amyloidosis. The diagnosis suggested by the echocardiographic but was confirmed by the damaged organ's biopsy. The present case concerns a young woman, who has hypertension and a pulmonary oedema. The echocardiographic scan showed a septal hypertrophy with a shining and granite-like aspect which is compatible with heart amyloidosis. Systolic and diastolic disorder with mitral and aortic regurgitation were also revealed. The kidney and rectum biopsies confirmed amyloidosis AL of the Kappa dysglobulinemia type, without extraosseous plasmocytoma. The heart and kidney failure symptoms disappeared after treatment with diuretics and ACE inhibitors.

[Primary hyperaldosteronism. Apropos of 2 cases]. / Hyperaldostéronisme primaire. A propos de 2 cas.

Primary hyperaldosteronism (PHA) represents less than 1 to 2% of all causes of hypertension (HT). We report 2 cases of primary hyperaldosteronism which emphasize the difficulty of distinguishing neoplastic PHA from idiopathic PHA, observed in a 60-year-old woman and a 42-year old woman, respectively. In both cases, the diagnosis of PHA was suggested by marked hypokalaemia with inappropriate potassium excretion and was confirmed by hyperaldosteronaemia and low and poorly stimulated renin activity. In the first case, computed tomography showed nodular hyperplasia of the 2 adrenal glands. The patient was treated with spironolactone and calcium channel blockers which controlled blood pressure and serum potassium. In the second case, computed tomography and magnetic resonance imaging revealed an adrenocortical adenoma confirmed by pathological examination after the operation. The diagnosis of primary hyperaldosteronism is based on three steps: detection, positive diagnosis and aetiological diagnosis. Detection is essentially based on demonstration of hypokalaemia. Positive diagnosis is based on demonstration of elevated aldosterone secretion with inhibited renin secretion. The aetiological diagnosis is dominated by the differentiation between Conn's adenoma and bilateral adrenal hyperplasia, which has therapeutic implications.

[Endomyocardial fibrosis of the right heart in Behçet disease]. / Fibrose endomyocardique du coeur droit au cours de la maladie de Behçet.

Cardiac involvement is rare in Behçet's disease. Endomyocardial fibrosis of the right heart is exceptionally rare and is associated with right ventricular thrombosis. The authors report the case of a 27 year old man who died of a massive pulmonary embolism and who suffered from right-sided endomyocardial fibrosis with intraventricular thrombi. The diagnosis was made at autopsy. Behçet's disease was diagnosed on the finding of bipolar aphthous ulcers and skin hypersensitivity. The authors support previous workers in stating that Behçet's disease should be considered as a possible cause of endomyocardial fibrosis of the right heart.

Acceptability and tolerance of ambulatory blood pressure measurement in the hypertensive patient.

OBJECTIVE: To establish the acceptability and tolerance of ambulatory blood pressure monitoring (ABPM). METHODS: A two-part questionnaire was completed by the doctor; one part before ABPM and the second after the recording. The pre-recording data concern the demographic data of the patient: previous illness, symptoms, reaction of the patient, anthropometric data, treatment details and the reason for ABPM. The second part of the questionnaire records the type of monitor used, the conditions of the recording and any difficulties for, or adverse effects on, the patient. SUBJECTS: Six hundred and seventy-two patients considered hypertension by World Health Organization criteria (diastolic blood blood pressure >/=90 mmHg, systolic blood pressure >/=140 mmHg), were considered for the first descriptive part of the study; a total of 654 patients were considered for the second part related to tolerance; 18 patients refused to reply to the questions concerning the second questionnaire. The general characteristics of the population were as follows: 345 men (51.5%), 327 women (48.5%) and mean age 54+/- 15 years. RESULTS: The devices used were SpaceLabs (63%), Novacor (19.3%), Nippon Collin (6.3%) and other machines (11.2%). The difficulties caused by the machine were classified as 'nul', 'moderate' or 'important'. The levels of difficulty defined as 'important' were 32% related to the cuff, 14% to the awkwardness of the machine and 6% to the noise of the monitor. Difficulty in driving was reported in 9% of cases and difficulty related to comments by colleagues in 6%. Analysis during sleep hindered sleep in 55%, with a very disturbed sleep pattern (more than three reported awakenings) in 14% of cases. Regression analysis allowed examination of the links among the different variables, taking into account the type of machine or the profile of the subject. Thus, it was possible to differentiate among the elements that could influence or predict intolerance. CONCLUSION: Recording-related problems are not negligible but can be reduced by an approach oriented towards each individual patients, taking into account specific information for particular circumstances.

[Ambulatory measurement of blood pressure]. / La mesure ambulatoire de la pression artérielle.

The advent of new techniques has greatly contributed to the development of ambulatory measurement as a noninvasive method for evaluating blood pressure. The technique implies use of a validated and reliable standardized apparatus. The operator must strictly comply with operating procedures, which must also be explained to the patient. Ambulatory measurement can be meaningful only if the results are compatible with reference values, which have now been established, and if the causes of possible error can be recognized and interpreted. Ambulatory blood pressure measurement has greatly improved our knowledge of physiological and pathological variations over the circadian cycle including day/night variability and the effects of psychosensorial stimulation. Diagnostic indications are clearly identified and include borderline hypertension suspected but not identified after about 3 months, the white coat effect, severe hypertension when modifications in the circadian cycle are suspected, paroxysmal hypertension, suspected pheochromocytoma, and gravid hypertension or an inversion of the circadian cycle possibly preceding an episode of eclampsia. There are also a certain number of particular indications in patients with degenerative or primary conditions affecting their autonomy. The true prognostic value of these recordings was recognized several years ago and has been confirmed by clinical trials. For example, the white blouse effect has no significant implication in terms or predicting less favourable morbidity or mortality. Finally, ambulatory blood pressure measurement has been definitively shown to be a valid method for evaluating the therapeutic effect of an anti-hypertensive drug in a given patient, especially when resting levels are questioned. For therapeutic trials, ambulatory measurements serve as a reference to evaluate the effect of treatment on the circadian cycle. Peak/dip levels can thus be determined in comparison with the residual effect of the drug. A large number of studies remain to done to identify the full potential of this method.

[Bacterial endocarditis in Morocco]. / L'endocardite bactérienne en milieu marocain.

This retrospective study was based on 157 cases of infectious endocarditis observed in the Cardiology department of Ibn Rochd Hospital in Casablanca between January 1983 and December 1994. The mean age of the patients was 27.5 years (11 to 65 years) with a male predominance (62.8%). Infectious endocarditis was secondary to rheumatic valvular heart disease in 63.% of patients and was primary in 29.9% of cases. Mitral or mitro-aortic valve involvement was clearly predominant. A portal of entry of the infection was identified in 63% of patients. It was dental in 64% of cases. Blood cultures were positive in 42% of cases with a predominance of unclassifiable Streptococci (37.8%) and coagulase-negative Staphylococci (25.7% of cases). Echocardiography was very useful, particularly in the presence of negative blood cultures. It demonstrated specific lesions of infectious endocarditis in 73.2% of cases and revealed very large, mobile vegetations in every case complicated by systemic embolism. The clinical course was complicated by heart failure (47.8%), renal failure (14.6%) or neurological lesions (11.5%). The global mortality was 28.7%, related to refractory heart failure in most cases.

[Cardiac manifestations of diffuse systemic scleroderma. Apropos of 4 cases]. / Manifestations cardiaques de la sclérodermie systémique diffuse. A propos de quatre observations.

Based on a series of four cases and a review of the literature, the authors describe the lesions of the various cardiac tissues in the course of systemic scleroderma. Pericardial involvement presents in the form of either acute pericarditis or chronic pericarditis. Pericardial tamponade is exceptional. Sclerodermal cardiomyopathy is frequent and serious and can be responsible for heart failure. Arrhythmias are frequent and may be either ventricular or supraventricular. Involvement of the conduction tissue often requires implantation of a pacemaker. Endocardial and valvular involvement is very rare. Lastly, coronary involvement appears to be fairly rare and responsible for vasospastic episodes in the coronary artery territory.

[Aortic coarctation and pregnancy. Apropos of 3 cases followed-up during a period of 10 years]. / Coarctation de l'aorte et grossesse. A propos de trois cas suivis pendant une période de 10 ans.

Classically, coarctation of the aorta is poorly tolerated during pregnancy or at least is associated with a risk of rupture of the aorta, rupture of a cerebral aneurysm or, more rarely, cardiac failure or bacterial infection. The authors turned their attention to this association of coarctation of the aorta and pregnancy in the light of 3 cases of pregnancy brought to term in the Department of Cardiology of the Ibn Rochd Teaching Hospital Group, Casablanca, Morocco. During a 10 year period, 20 patients were hospitalised in the department with coarctation of the aorta. There were 10 women, 3 of them pregnant. The mean age of these women was 26, with a range of 24 to 30. All patients had a normal pregnancy, delivery and post-partum, with neither cardiovascular, renal nor cerebral complications. There were no maternal deaths, ruptures of the aorta, cerebrovascular accidents, bacterial infections nor myocardial failure. All the pregnancies were brought to term. One patient was delivered vaginally with the use of forceps after full dilatation facilitating expulsion. One cesarean section with extraction of a live infant was induced at 38 weeks. One patient was lost to follow-up at 7 months and was seen again only after delivery at home, i.e. without supervision but equally without complications. The 3 newborn infants had an Apgar of 10/10 and a birth weight of 3.2-3.5 kilos. There were no spontaneous abortions and no premature deliveries.(ABSTRACT TRUNCATED AT 250 WORDS)