Divertículo submitral congénito / Congenital submitral diverticulum

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Mujer de 77 años con anomalías en el pulso / 77-year-old woman with pulse abnormalities

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[Echographic diagnosis of systolic murmur among 280 young French militaries. Implications for the expertise in military medicine]. / Diagnostic échographique d'un souffle cardiaque systolique au sein d'une population de 280 jeunes militaires français. Implications en médecine d'expertise militaire.

UNLABELLED: Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries. METHODS: We ran a retrospective monocentric study in the "Clermont-Tonnerre" military hospital in Brest. We included all patients sent for TEE, aged 15 to 30 years old, from the 1st January 2010 until the 31st July 2013. RESULTS: Two hundred and eighty TTES assessing CSM were performed. We found 28/280 (10%) echocardiographic abnormalities: 13 were bicuspid aortic valves (4.6%), 6 were ventricular septal defects (2.15%), 3 were atrial septal defects (1.07%), 4 were mild mitral regurgitations (1.43%), one mild pulmonary stenosis (0.35%) and one aortic stenosis (0.35%). No hypertrophic cardiomyopathy was found. Concerning military expertise, 11 (3.92%) patients among these 28 with abnormal TEE were considered unfit for work or "fit for work with limitations". CONCLUSION: Assessing a cardiac systolic murmur with TEE lead to the diagnosis of a cardiomyopathy in 10% of the case. This study enhances the importance of systematic TEE when a CSM is detected in the young military, in order to determine if those soldiers can still fulfill their military duty.

Evaluation of systolic murmurs using transthoracic echocardiography by anaesthetic trainees.

Focused transthoracic echocardiography by anaesthetists in the peri-operative period has recently been described; the data suggest that the specific skills required can be obtained by non cardiology physicians with limited training. Aortic stenosis is known to increase significantly the peri-operative risk in non-cardiac surgery. This study aimed to assess the ability of echocardiography naive trainee anaesthetists to recognise and assess the severity of aortic stenosis after a set amount of training. Five trainees underwent 2 h of didactic and hands-on teaching in evaluation of the aortic valve, after which they scanned 20 patients each. Their results were compared with those obtained by an experienced cardiac anaesthetist with echocardiography training and qualifications. There was 100% concordance between trainees and the consultant for assessment of clinically significant aortic stenosis, with no cases of misdiagnosis. There was also 90-100% agreement (kappa statistic 0.8-1) between the consultant and each trainee's assessment of clinically significant aortic stenosis based on a peak aortic velocity > 3 m.sec(-1). Anaesthesia trainees can be successfully and rapidly trained to recognise and estimate the severity of aortic stenosis.

Etiology and diagnosis of systolic murmurs in adults.

BACKGROUND: It is unknown whether echocardiography can provide insights into the origin of systolic murmurs and the modern value of bedside cardiovascular diagnosis. METHODS: The author examined 376 inpatients and compared their physical findings to transthoracic echocardiography, exploring the associations between echocardiography and systolic murmurs and investigating the diagnostic accuracy of physical examination for pathologic murmurs. RESULTS: Four echocardiographic variables predict the presence of systolic murmurs: peak aortic velocity (P <.001); mitral regurgitation severity (P <.001); mitral valve E-point velocity (P=.09); and absence of pericardial effusion (P=.09). When diagnosing murmurs, the most helpful finding is its distribution on the chest wall with respect to the 3(rd) left parasternal space, a landmark that distinguishes murmurs into 6 patterns. The "apical-base" pattern indicates increased aortic velocity (likelihood ratio [LR] 9.7; 95% confidence interval [CI]; 6.7-14): a delayed carotid upstroke (LR 6.8; 95% CI; 4.0-11.5); absent S2 (LR 12.7; 95% CI; 5.3-30.4); and humming quality to the murmur (LR 8.5; 95% CI; 4.3-16.5) further increase the probability of aortic valve disease. The "broad apical" murmur pattern suggests significant mitral regurgitation (LR 6.8; 95% CI; 3.9-11.9); and the "left lower sternal" murmur pattern indicates significant tricuspid regurgitation (LR 8.4; 95% CI; 3.5-20.3): additional bedside observations refine these diagnoses. Nonetheless, this study shows that some classic physical findings are no longer accurate, that physical examination cannot reliably distinguish severe aortic stenosis from less severe stenosis, and that classic physical findings, despite having proven value, are absent in many patients with significant cardiac lesions. CONCLUSIONS: In the diagnosis of systolic murmurs, physical examination has limitations but also unappreciated value. A simple system using onomatopoeia and classifying systolic murmurs into 1 of 6 patterns is diagnostically helpful.

An unusual cause of left ventricular outflow tract obstruction: the importance of a new systolic murmur with a large pleural effusion.

BACKGROUND: Left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve occurs as a result of a dynamic interplay between the anatomy and mechanics of the heart. While systolic anterior motion and left ventricular outflow tract obstruction are well-recognized hallmarks of hypertrophic obstructive cardiomyopathy, several other specific etiologies have been described with similar pathophysiology. CASE REPORT: We present a unique case of a middle-aged woman who developed acute dynamic left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve resulting from a large left-sided pleural effusion. CONCLUSIONS: Dynamic outflow tract obstruction should be considered among the potential causes of a new systolic murmur in patients with large pleural effusions in the absence of valvular heart disease.

Resolution of a giant atrial thrombus following anticoagulation therapy.

We report on a patient in whom a giant thrombus in the left atrium was detected by transthoracic echocardiography. Anticoagulant theraphy was started. After two months of therapy, repeat echocardiography showed complete resolution of the thrombus. This case indicates that large and presumably organised thrombi may be treated with anticoagulant therapy.