[Monocentric retrospective study on the prevalence and significance of incomplete right bundle branch block in young competitive athletes in Tunisia]. / Étude rétrospective monocentrique sur la prévalence et la signification du bloc de branche droit incomplet chez les jeunes sportifs de compétition en Tunisie.

AIMS: Few studies have assessed the prevalence and significance of right bundle branch block in athletes. Aims of this study were to evaluate the prevalence of incomplete right bundle branch block and its correlation with the nature of sports practice and to compare the athlete with right bundle branch block and the one with a normal electrocardiogram. METHODS: It was a retrospective study of the electrocardiogram and echocardiography of competitive athletes recruited in the medical-sports center of Sousse RESULTS: A total of 554 athletes were included. Mean age was 16.1 ± 2.9 years and 69 % were male. The mean training duration was 5.8 hours per week. The prevalence of incomplete right bundle branch block was 13.9 % (77 cases). Endurance sports were practiced in 71.4 % of cases among subjects with right bundle branch block versus 55.4 % in the rest of the population (p < 0.001). The basal diameter of the right ventricle was larger in athletes with right bundle branch block compared to athletes without right bundle branch block: 28 ± 3.6 mm versus 24 ± 2.4 mm (p < 0.001). CONCLUSIONS: The results of this study suggest that right bundle branch block is a marker of incomplete right ventricular remodeling. This remodeling represents a form of adaptation to sustained elevation of volumetric load observed mainly in endurance sports.

[Clinical and echocardiographic parameters associated with the alteration of global longitudinal strain in secondary mitral regurgitation]. / Paramètres cliniques et échocardiographiques associés à l'altération du strain longitudinal global dans l'insuffisance mitrale secondaire.

INTRODUCTION: Left ventricular systolic function may be overestimated in patients with secondary mitral regurgitation when using left ventricle ejection fraction. The Global longitudinal strain is a measure less dependent on left ventricle load. However, the clinical and echocardiographic parameters associated with the alteration of Global longitudinal strain in secondary mitral regurgitation have not been evaluated. MATERIAL AND METHODS: A total of 96 patients (mean age 62.3 ± 12.1 years, 59.3% male) with secondary mitral regurgitation and low left ventricle ejection fraction < 50% were included. The study population was subdivided according to the Global longitudinal strain value with which an increased risk of all-cause mortality was associated (Global longitudinal strain < 7.0%, left ventricle systolic function impaired compared to Global longitudinal strain ≥ 7.0%, in absolute value). The clinical and echocardiographic endpoints are analysed in both groups of patients. RESULTS: The strong and clear correlation between Global longitudinal strain (mean ± standard deviation: 7,2 ± 2,7) and parameters of systolic function (left ventricle ejection fraction mean ± standard deviation: 32,4 ± 8,0%) and contractility (dp/dt mean ± standard deviation: 682,5 ± 204,7 mmHg/s). the mean of left ventricle ejection fraction = 26.4 ± 5.3% in the Global longitudinal strain < 7 group, and the bivariate study using the 30% threshold shows that the Global longitudinal strain < 7 group presents a more altered left ventricle ejection fraction with odds ratio = 12, 5 (CI: 4.7-33.0) p < 0.001. In multivariate analysis of ultrasound parameters and linear regression shows a significant correlation between Global longitudinal strain and left ventricle ejection fraction (p < 0.001). The dp/dt analysis found a mean of 509.3 ± 99.1 mmHg/s in the Global longitudinal strain < 7 group and of 822.9 ± 154.1 in the Global longitudinal strain ≥ 7 group with significant difference (p < 0.001). In bivariate and multivariate analysis, the alteration of Global longitudinal strain is associated with a significantly lower dp / dt p < 0.001. CONCLUSION: A Global longitudinal strain < 7 (in absolute value) reflects a severe impairment of left ventricle function. In addition, several parameters were associated with this severe alteration of the Global longitudinal strain, namely a lower left ventricle ejection fraction, a lower dp/dt and more severe symptoms permitting to characterized this group of patients in addition to an integration in a multiparametric evaluation of the secondary mitral regurgitation.

[Long-term repaired tetralogy of Fallot : Echocardiographic parameters in correlation with cardiac MRI]. / Tétralogie de Fallot réparée au long terme : paramètres échographiques en corrélation avec l'IRM cardiaque.

INTRODUCTION: Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease. After surgical repair, the excellent survival rate has led to long-term complications dominated by pulmonary regurgitation (PR). Our study aimed to identify echocardiographic criteria for assessment of right ventricular (RV) function and quantification of PR correlated with cardiac MRI indices. METHODS: We conducted a descriptive study between June 2021 and March 2022 including patients followed for repaired ToF since 2016 or earlier. All patients were seen for clinical, electrocardiographic, and ultrasound evaluation. Cardiac MRI was performed with a maximum delay of 1 month from Doppler echocardiography. RESULTS: 38 patients were included, with a mean age at imaging of 18 ± 9 years. Our study showed that the echocardiographic parameters of PR quantification correlated with a pulmonary regurgitation fraction on MRI greater than 40% were: the PHT value (p = 0.005) and the ratio of PR jet width to pulmonary valve annulus diameter (p = 0.032). The only ultrasound parameter estimating RV systolic function correlated with RVEF on cardiac MRI was FAC, with p = 0.007. CONCLUSION: Quantitative assessment of RV parameters in patients followed for repaired ToF, as well as the assessment of the severity of PR, is feasible with a standardized ultrasound examination, with good correlation with cardiac MRI.

[Bullet fragment in the interventricular septum : Is surgery always obligatory ?] / Fragments de balle dans le septum interventriculaire : faut-il opérer à tout prix ?

INTRODUCTION: Cardiac gunshot injuries are fatal and very challenging to manage for surgeons. Unfortunately, there is no consensus regarding the management of these patients. CASE PRESENTATION: We report an unusual case of a cardiac injury after an indirect gunshot to the heart. The 59 years-old male was hemodynamically stable which allowed us to do further investigations revealing a bullets fragment in the interventricular septum without other complication. Conservative management was decided with a careful regular follow-up. CONCLUSION: Cardiac gunshot injuries must be managed aggressively in hemodynamically unstable patients. In stable patients, further investigations can be done to allow decision-making.

Endurance training-induced cardiac remodeling in a guinea pig athlete's heart model.

Besides the health benefits of regular exercise, high-level training-above an optimal level-may have adverse effects. In this study, we investigated the effects of long-term vigorous training and its potentially detrimental structural-functional changes in a small animal athlete's heart model. Thirty-eight 4-month-old male guinea pigs were randomized into sedentary and exercised groups. The latter underwent a 15-week-long endurance-training program. To investigate the effects of the intense long-term exercise, in vivo (echocardiography, electrocardiography), ex vivo, and in vitro (histopathology, patch-clamp) measurements were performed. Following the training protocol, the exercised animals exhibited structural left ventricular enlargement and a significantly higher degree of myocardial fibrosis. Furthermore, resting bradycardia accompanied by elevated heart rate variability occurred, representing increased parasympathetic activity in the exercised hearts. The observed prolonged QTc intervals and increased repolarization variability parameters may raise the risk of electrical instability in exercised animals. Complex arrhythmias did not occur in either group, and there were no differences between the groups in ex vivo or cellular electrophysiological experiments. Accordingly, the high parasympathetic activity may promote impaired repolarization in conscious exercised animals. The detected structural-functional changes share similarities with the human athlete's heart; therefore, this model might be useful for investigations on cardiac remodeling.

Right ventricle-pulmonary artery coupling in repaired tetralogy of Fallot with pulmonary regurgitation: Clinical implications.

BACKGROUND: Right ventricle-pulmonary artery (RV-PA) coupling is a strong prognostic marker in several clinical settings, but few studies have focused on its role in repaired tetralogy of Fallot (rToF) with pulmonary regurgitation. AIM: To assess whether differences exist in RV-PA coupling, estimated by echocardiography, between patients with rToF and pulmonary regurgitation with or without an indication for pulmonary valve replacement (PVR). METHODS: The study population included 40 patients with rToF, who were allocated to two groups: 20 with an indication for PVR (i-PVR group); and 20 without an indication for PVR (ni-PVR group). Forty healthy controls were also included. All subjects underwent echocardiography, and cardiac magnetic resonance (CMR) was available in 27/40 patients with rToF. RV-PA coupling was assessed by echocardiographic tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure (TAPSE/PASP) and right ventricular stroke volume/right ventricular end-systolic volume (RVSV/RVESV) by CMR. RESULTS: TAPSE was similar in the i-PVR and ni-PVR groups (19.0±3.4 vs 18.8±2.7mm; P=0.97) whereas RV-PA coupling was significantly worse in the i-PVR group versus the ni-PVR group (TAPSE/PASP 0.8±0.3 vs 1.1±0.5mm/mmHg; P=0.001), and in the i-PVR group versus the control group (P=0.02); there was no difference between the ni-PVR and control groups (P=0.29). CMR data confirmed the echocardiography results, with a significant difference in RV-PA coupling between the i-PVR and ni-PVR groups (RVSV/RVESV 0.9±0.2 vs 1.2±0.3mL/min/mL; P=0.01). CONCLUSIONS: This study demonstrates worse RV-PA coupling, despite normal RV systolic function, in patients with rToF with an indication for PVR. RV-PA coupling could be a sensitive marker of a progressive maladaptive RV response to long-standing volume overload in rToF before the onset of clinical symptoms and RV systolic dysfunction.

[Cardiac imaging in infiltrative cardiomyopathies. What cardiovascular imaging modalities to propose in hypertrophic cardiomyopathies ?] / Rôle de l'imagerie cardiaque dans les cardiomyopathies infiltratives: Quels examens d'imagerie demander devant une hypertrophie ventriculaire gauche ?

Infiltrative cardiomyopathies are abnormal accumulations or depositions of different substances in cardiac tissue leading to its dysfunction, first diastolic, then systolic. The different infiltrative cardiomyopathies are amyloidosis (both light chain amyloidosis and transthyretin amyloidosis variants), lysosomal and glycogen storage disorders (Fabry-Anderson disease), and iron overload (hemochromatosis and thalassemia associated with blood transfusions), as well as inflammatory diseases such as sarcoidosis. We also evoke hypereosinophilic syndrome associated with endomyocardial fibrosis. Echocardiography is the first essential step after interrogatory and clinical examination and may help the cardiologist as a screening tool. Cardiac MRI is the second fundamental step towards the diagnosis especially due to the late gadolinium enhancement and to the T1-mapping. Cardiac amyloidosis diagnosis also requires the use of nuclear imaging. Cardiac CT-Scan may be useful for estimating the amyloid load, identify potential cardiac thrombus and rule out associated coronaropathy.

[Left ventricular hypertrophy in hemodialysis patient: Prevalence, electrocardiographic, echocardiographic study and associated risk factors]. / Hypertrophie ventriculaire gauche chez les hémodialysés : prévalence, étude électrique, échographique et facteurs de risque.

BACKGROUND: Left ventricular hypertrophy is the most prevalent cardiac abnormality in hemodialysis patients. The diagnosis of this abnormality is possible by electrocardiogram and/or echocardiography. Our study aimed to assess the prevalence of left ventricular hypertrophy in hemodialysis patients and the accuracy of different electrocardiographic criteria. METHODS: This was a cross-sectional retrospective study including 60 hemodialysis patients between 2017 and 2018. A left ventricular mass index higher than 115g/m2 and 95g/m2 respectively in men and women defines echocardiographic left ventricular hypertrophy. We assessed left ventricular hypertrophy prevalence, sensitivity, specificity, and area under the receiver-operating characteristics (ROC) curve of fourteen different electrocardiographic criteria for identification of left ventricular hypertrophy. RESULTS: This was a cohort of 60 patients composed of 27 men and 33 women with a mean age 52.6±15,8years. Hypertension was the most common cardiovascular risk factor (82 %). The prevalence of left ventricular hypertrophy at echography was 65 %. Prevalence of left ventricular hypertrophy at electrocardiographic varied across the different criteria ranging from 5 % (R wave in DI) to 32 % (Perugia score). The highest left ventricular hypertrophy prevalence at electrocardiographic was found with the five following criteria: Perugia score (32 %), Peguero-Lo Presti index (28 %), Sokolow-Lyon index, Cornell index, Framingham-adjusted Cornell voltage (17 %). Sensitivity was ranged from 5 % (R in DI, Gubner-Ungerleider index, and product) to 41 % (Perugia score). The specificity of most criteria was ≥90 % except for the Perugia score (85 %). The sensitivity, specificity, postitive and negative productive values and left ventricular hypertrophy prevalence using the five most accurate criteria combined were respectively 48, 90, 70.28, 77.85 and 33 %. Hypertension, duration of HD, arteriovenous fistula, interdialytic weight gain, systolic blood pressure, hemoglobin <9g/dL and hyperparathyroidism were significantly associated with left ventricular hypertrophy. CONCLUSION: The prevalence of left ventricular hypertrophy detected by echocardiography was high. All electrocardiographic criteria had a low sensibility and a high specificity in the diagnostic of echocardiographic left ventricular hypertrophy. To improve the accuracy of electrocardiographic criteria, it is necessary to combine several electrocardiographic criteria and not often focused on a single classic electrocardiographic index.

Characterizing cardiac phenotype in Friedreich's ataxia: The CARFA study.

BACKGROUND: Friedreich's ataxia is an autosomal recessive mitochondrial disease caused by a triplet repeat expansion in the frataxin gene (FXN), exhibiting cerebellar sensory ataxia, diabetes and cardiomyopathy. Cardiac complications are the major cause of early death. AIMS: To characterize the cardiac phenotype associated with Friedreich's ataxia, and to assess the evolution of the associated cardiopathy over 1 year. METHODS: This observational single-centre open label study consisted of two groups: 20 subjects with Friedreich's ataxia and 20 healthy controls studied over two visits over 1 year. All subjects had transthoracic echocardiography, cardiac magnetic resonance imaging, cardiopulmonary exercise testing, quantification of serum cardiac biomarkers and neurological assessment. RESULTS: Patients with Friedreich's ataxia had left ventricular hypertrophy, with significantly smaller left ventricular diastolic diameters and volumes and increased wall thicknesses. Cardiac magnetic resonance imaging demonstrated significant concentric left ventricular remodelling, according to the mass/volume ratio, and focal myocardial fibrosis in 50% of patients with Friedreich's ataxia. Cardiopulmonary exercise testing showed alteration of left ventricular diastolic filling in patients with Friedreich's ataxia, with an elevated VE/VCO2 slope (ventilatory flow/exhaled volume of carbon dioxide). High-sensitivity troponin T plasma concentrations were higher in subjects with Friedreich's ataxia. None of the previous variables changed at 1 year. Neurological assessments remained stable for both groups, except for the nine-hole pegboard test, which was altered over 1 year. CONCLUSIONS: The multivariable characterization of the cardiac phenotype of patients with Friedreich's ataxia was significantly different from controls at baseline. Over 1 year there were no clinically significant changes in patients with Friedreich's ataxia compared with healthy controls, whereas the neurological severity score increased modestly.

[Coronary artery aneurysm in Kawasaki disease and its risk factors : a retrospective study about 65 Tunisian children]. / Les complications coronaires de la maladie de Kawasaki et ses facteurs de risque : à propos de 65 cas d'enfants tunisien.

INTRODUCTION: Kawasaki syndrome (KS) is a systemic vasculitis of unknown etiology that affects medium and small blood vessels. The aim of our study is to analyze coronary artery lesions in children with KS and their risk factors. MATERIAL AND METHODS: All children under the age of 15 years-old presenting KS and admitted in the pediatric department of three university hospital (Sahloul hospital, and Farhat Hached hospital of Sousse, Ibn El Jazzar hospital of Kairoun) from January 2000 to December 2018 were included. RESULTS: Sixty-five patients were included in our study. The mean age at diagnosis was of 29.9 months [2-120 months] and the sex ratio was of 1.7. Echocardiography was performed in all patients. It showed coronary dilation in 37% of patients with coronary artery diameter of 4.2 mm on average [3.2-7mm]. The coronary aneurysm was small in 19 cases and medium in 5 cases. No giant aneurysm has been identified. In univariate analysis, the predictors of coronary artery lesions were male sex, atypical form, fever duration more than 10 days, hepatic cytolysis, thrombocytosis and anemia. In multivariate analysis, only the last four parameters were the predictive factors of the coronary artery involvement. CONCLUSION: Several risk factors can be used to determine which children are predisposed to develop coronary dilations. In case of patient with risk factors, intravenous immunoglobulins should be initiated early to avoid these serious complications.

[Opportunistic screening for abdominal aortic aneurysm during echocardiography in patients with coronary artery disease: Utility or futility?] / Dépistage opportuniste de l'anévrysme de l'aorte abdominale lors de l'échocardiographie chez le patient coronarien : utile ou futile ?

Abdominal aortic aneurysm is a chronic degenerative disease that is usually silent until rupture occurs and this complication is still associated in contemporary era with a high rate of mortality. Screening programmes for abdominal aortic aneurysm have been shown to be effective in reducing global mortality in the screened population but these programmes are poorly implemented in the Western countries. As coronary artery disease and abdominal aorta aneurysmal disease share many risk factors, the cardiologist is centrally positioned in the screening strategy, not only to identify patients with higher risk of developing abdominal aortic aneurysm, but also to perform an opportunistic screening during echocardiography. This paper summarises evidence about the feasibility, indications, modalities, benefits and risks related to the opportunistic screening for abdominal aortic aneurysm during echocardiography with a particular emphasis on the population of patients with coronary artery disease.

Post hoc assessment of the relationship among coronary stenosis, electrocardiography, and ventricular function in patients with heart disease.

Cardiovascular diseases including cardiac arrhythmias lead to fatal events in patients with coronary artery disease; however, clinical associations from echocardiography, electrocardiography (ECG), and biomarkers remain unknown. We sought to identify the factors that may be related to elevated QRS intervals in patients with risk for coronary artery disease. In this study, we performed analysis of clinical data from 503 patients divided into two groups, i.e., patients with either <50% coronary artery stenosis or >50% coronary artery stenosis. We further examined patients with elevated ECG parameters such as QRS > 100 ms and QTc > 440 ms. Patients with >50% coronary artery stenosis exhibited significant increases in age, triglycerides, and troponin levels. Further, ECG parameters demonstrated increased QRS and QTc durations, while echocardiographic parameters highlighted a decrease in ejection fraction (EF) and fractional shortening (FS). Patients with QTc > 440 ms exhibited increased brain natriuretic peptide and creatinine levels with a decrease in estimated glomerular filtration rate clearance rates. Patients with QRS > 100 ms had greater left ventricular (LV) mass and LV internal diameter in systole and diastole. Multimodal logistic regression showed significant relation between QTc, age, and creatinine. These findings suggest that patients with significant coronary stenosis may have lower EF and FS with prolonged QRS intervals, demonstrating greater risk for arrhythmic events.

Determinants of arterial stiffness in patients with atrial fibrillation.

BACKGROUND: Arterial stiffness has emerged as a strong predictor of cardiovascular disease, end-organ damage and all-cause mortality. Although increased arterial stiffness has been described as a predictor of atrial fibrillation, the relationship between arterial stiffness and atrial fibrillation is uncertain. AIM: We assessed arterial stiffness in patients with atrial fibrillation compared with that in a control group. METHODS: We enrolled 151 patients with atrial fibrillation who underwent pulmonary vein isolation (mean age 71.1±9.8 years) and 54 control patients with similar cardiovascular risk profiles and sinus rhythm, matched for age (mean age 68.6±15.7 years) and sex. Aortic distensibility as a measure of arterial stiffness was assessed by transoesophageal echocardiography. Patients with atrial fibrillation were followed over a median of 21 (15 to 31) months. RESULTS: Compared with control patients, patients with atrial fibrillation had significantly lower aortic distensibility (1.8±1.1 vs. 2.1±1.1 10-3mmHg-1; P=0.02). Age (hazard ratio 0.67, 95% confidence interval 0.003 to 0.03; P=0.02) and pulse pressure (hazard ratio -1.35, 95% confidence interval -0.07 to -0.03; P<0.0001) were the strongest predictors of decreased aortic distensibility in the study cohort. This effect was independent of the type of atrial fibrillation (paroxysmal/persistent). During follow-up, decreased aortic distensibility was a predictor of cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, with a higher incidence rate of events in patients in the lowest aortic distensibility quartile (P=0.001). CONCLUSIONS: Aortic distensibility was significantly reduced in patients with atrial fibrillation, with age and pulse pressure showing the strongest correlation, independent of the type of atrial fibrillation. Additionally, decreased aortic distensibility was associated with cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, which showed a quartile-dependent occurrence.

Clinical and prognostic implications of phenomapping in patients with heart failure receiving cardiac resynchronization therapy.

BACKGROUND: Despite having an indication for cardiac resynchronization therapy according to current guidelines, patients with heart failure with reduced ejection fraction who receive cardiac resynchronization therapy do not consistently derive benefit from it. AIM: To determine whether unsupervised clustering analysis (phenomapping) can identify distinct phenogroups of patients with differential outcomes among cardiac resynchronization therapy recipients from routine clinical practice. METHODS: We used unsupervised hierarchical cluster analysis of phenotypic data after data reduction (55 clinical, biological and echocardiographic variables) to define new phenogroups among 328 patients with heart failure with reduced ejection fraction from routine clinical practice enrolled before cardiac resynchronization therapy. Clinical outcomes and cardiac resynchronization therapy response rate were studied according to phenogroups. RESULTS: Although all patients met the recommended criteria for cardiac resynchronization therapy implantation, phenomapping analysis classified study participants into four phenogroups that differed distinctively in clinical, biological, electrocardiographic and echocardiographic characteristics and outcomes. Patients from phenogroups 1 and 2 had the most improved outcome in terms of mortality, associated with cardiac resynchronization therapy response rates of 81% and 78%, respectively. In contrast, patients from phenogroups 3 and 4 had cardiac resynchronization therapy response rates of 39% and 59%, respectively, and the worst outcome, with a considerably increased risk of mortality compared with patients from phenogroup 1 (hazard ratio 3.23, 95% confidence interval 1.9-5.5 and hazard ratio 2.49, 95% confidence interval 1.38-4.50, respectively). CONCLUSIONS: Among patients with heart failure with reduced ejection fraction with an indication for cardiac resynchronization therapy from routine clinical practice, phenomapping identifies subgroups of patients with differential clinical, biological and echocardiographic features strongly linked to divergent outcomes and responses to cardiac resynchronization therapy. This approach may help to identify patients who will derive most benefit from cardiac resynchronization therapy in "individualized" clinical practice.

Simulation-based training in cardiology: State-of-the-art review from the French Commission of Simulation Teaching (Commission d'enseignement par simulation-COMSI) of the French Society of Cardiology.

In our healthcare system, mindful of patient safety and the reduction of medical errors, simulation-based training has emerged as the cornerstone of medical education, allowing quality training in complete safety for patients. Initiated by anaesthesiologists, this teaching mode effectively allows a gradual transfer of learning, and has become an essential tool in cardiology teaching. Cardiologists are embracing simulation to master complex techniques in interventional cardiology, to manage crisis situations and unusual complications and to develop medical teamwork. Simulation methods in cardiology include high-fidelity simulators, clinical scenarios, serious games, hybrid simulation and virtual reality. Simulation involves all fields of cardiology: transoesophageal echocardiography, cardiac catheterization, coronary angioplasty and electrophysiology. Beyond purely technical issues, simulation can also enhance communication skills, by using standardized patients, and can improve the management of situations related to the announcement of serious diseases. In this review of recent literature, we present existing simulation modalities, their applications in different fields of cardiology and their advantages and limitations. Finally, we detail the growing role for simulation in the teaching of medical students following the recent legal obligation to use simulation to evaluate medical students in France.

Cardiovascular responses during submaximal cycling with and without left-lateral tilting: insights for practical applications of stress echocardiography.

We investigated the cardiorespiratory responses to semi-supine exercise with (SS+45°) and without (SS-0°) a left-lateral tilt in 15 adults at fixed power output (70 W) and matched heart rates. At 70 W, oxygen uptake and heart rate reduced from upright to SS-0° then increased to SS+45° (p < 0.05). At matched heart rates, oxygen uptake and efficiency were lowest in SS+45° (p < 0.05). Left-lateral tilting should not be performed under the assumption that each position replicates the same cardiorespiratory responses. Novelty: Cardiorespiratory responses to exercise are influenced by left-lateral tilting, which should not be performed under the assumption that physiological responses are replicated between left-lateral positions.

Monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia.

The surveillance strategy for patients taking low dose cabergoline for hyperprolactinaemia is controversial. As more evidence has emerged that the risks of cardiac valvulopathy in this population of patients are low, fewer and fewer endocrinologists adhere strictly to the original medicines and healthcare products agency MHRA guidance of "at least" annual echocardiography. Strict adherence to this guidance would be costly in monetary terms (£5.76 million/year in the UK) and also in resource use (90,000 extra echocardiograms/year). This article reviews the proposed pathophysiological mechanism underlying the phenomenon of dopamine agonist valvulopathy, the characteristic echocardiographic changes seen, summarises the published literature on the incidence of valvulopathy with low dose cabergoline and examines the previous and current evidence-based screening guidelines.

Value of preoperative echocardiography for the diagnosis of coronary artery patterns in neonates with transposition of the great arteries.

BACKGROUND: Abnormal coronary pattern may complicate coronary transfer during arterial switch operation. OBJECTIVE: To evaluate the accuracy of echocardiography in assessing the anatomy of coronary arteries in neonates with transposition of the great arteries, and determine impact on outcomes. METHODS: We conducted a retrospective analysis of data in neonates with transposition of the great arteries. Preoperative echocardiographic coronary artery pattern and surgical intraoperative reports were compared. Mismatch between transthoracic echocardiography and surgical intraoperative reports and the impact on perioperative outcome were assessed. Coronary patterns were classified into four groups: type 1 (normal); type 2 (risk of coronary with intramural course); type 3 (coronary loop); and type 2+3. RESULTS: Overall, 108 neonates who underwent an arterial switch operation were included: 68 were classified as type 1; seven as type 2; 32 as type 3; and one as type 2+3. Overall, 10 adverse events occurred. Five patients died, three from coronary causes. Survival was 96% at 1 month. Transthoracic echocardiography and surgical intraoperative reports differed in 17.6% of cases. Mortality was 15.8% in case of inappropriate diagnosis and 2.2% for appropriate diagnosis (P=0.01). Mortality in type 2 was 66.7% in case of discordance versus 0% when concordant. Multivariable analysis found that inappropriate preoperative transthoracic echocardiography diagnosis of coronary pattern was the only significant risk factor for mortality (P=0.04). CONCLUSIONS: Echocardiography can assess coronary artery anatomy in neonates with transposition of the great arteries. Intramural coronary course is often misdiagnosed. Preoperative misdiagnosis of coronary artery anomaly may impact perioperative mortality. However, this assessment will have to be confirmed by further larger studies.