[Cardiac hydatid cyst. Which imaging modality for an accurate diagnosis?] / Le kyste hydatique du cœur. Quelle modalité d'imagerie pour un diagnostic précis ?

Cardiac echinococcosis is rare. Its spontaneous course is serious because of the risk of rupture. Its clinical manifestations are variable, often latent and misleading. The diagnosis is sometimes referred to by chest radiography. It is much facilitated by non-invasive imaging techniques in particular transesophageal and transthoracic echocardiography, CT scan and magnetic resonance imaging. The latter through a morphological and topographical analysis accurate diagnosis of hydatid cyst and its relationship to cardiac muscle and surrounding tissue. Through functional analysis in cine cyst movements relative to the heart wall, it confirms its free or fixed character in the heart chambers, determines its insertion area, its deformability, the risk of rupture and its impact on myocardial contraction. Our case illustrates the relative contribution of these different imaging techniques and their respective contributions to the identification of hydatid cyst of its wall, its contents, its relationship with the various tunics and heart chambers and its relations with the lungs and mediastinum.

[Management of patients treated for acute ST-elevation myocardial infarction in Tunisia: Preliminary results of FAST-MI Tunisia Registry from Tunisian Society of Cardiology and Cardiovascular Surgery]. / Prise en charge de l'infarctus du myocarde en Tunisie : résultats préliminaires du registre FAST-MI Tunisie de la Société tunisienne de cardiologie et de chirurgie cardiovasculaire.

UNLABELLED: FAST-MI Tunisian registry was initiated by the Tunisian Society of Cardiology and Cardio-vascular Surgery to assess characteristics, management, and hospital outcomes in patients with ST-elevation myocardial infarction (STEMI). METHODS: We prospectively collected data from 203 consecutive patients (mean age 60.3 years, 79.8 % male) with STEMI who were treated in 15 public hospitals (representing 68.2 % of Tunisian public centres treating STEMI patients) during a 3-month period at the end of 2014. The most common risk factor was tobacco (64.9 %), hypertension (38.6 %), diabetes (36.9 %) and dyslipidemia (24.6 %). RESULTS: Among these patients, 66 % received reperfusion therapy, 35 % with primary percutaneous coronary interventions (PAMI), 31 % with thrombolysis (28.6 % of them by pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 and 358 min for PAMI, respectively. The in-hospital mortality was 7.0 %. Patients enrolled in interventional centers (n=156) were more likely to receive any reperfusion therapy (19.8 % vs 44.6 %; p<0.001) than at the regional system of care with less thrombolysis (26.9 % vs 44.6 %; p=0.008) and more PAMI (52.8 % vs 8.5 %; p<0.0001). Also the in-hospital mortality was lower (6.4 % vs 9.3 %) but not significant. CONCLUSIONS: Preliminary results from FAST-MI in Tunisia show that the pharmaco- invasive strategy should be promoted in non-interventional centers.

Interleukin-10 microsatellite variants and the risk of acute coronary syndrome among Tunisians.

The objective of the study was to investigate the association of interleukin (IL)-10 promoter microsatellite polymorphisms, linked with altered IL-10 secretion, with the susceptibility to acute coronary syndrome (ACS) in adult Tunisian patients. We genotyped 291 ACS patients and 291 age-, gender- and ethnically matched control subjects for the microsatellites IL-10R [X78437.2g.5325CA(11_15)] and IL-10G [X78437.2g.8134CA(14_29)] by PCR-based assays. Haplotypes were reconstructed using maximum likelihood method. Regression analysis was used in determining the risk imparted by specific IL-10 genotypes and haplotypes. A significant decrease in IL-10G12 (24 CA repeats) (P<0.001; OR=0.465) and IL-10G15 (27 CA repeats) (P=0.043; OR=0.232), and a significant increase in the low IL-10 producer allele, IL-10R3 (14 CA repeats) (P=0.049; OR=1.461), microsatellites were seen in the ACS group compared with controls. Of the possible 14 haplotypes constructed, there was an enrichment of the R2G9 (13CA vs. 21CA) haplotype in controls [P=0.019; adjusted OR (95% CI)=0.67 (0.48-0.94)] and R2G15 (13CA vs. 27CA) haplotype in cases [P=0.042; adjusted OR (95% CI)=5.29 (1.06-26.30)], thus assigning a protective and susceptible nature to these haplotypes respectively. The differential association of IL-10 microsatellite alleles and haplotypes with ACS suggests that IL-10 contributes to ACS pathogenesis. While the functional attributes of these microsatellite markers remain to be seen, it is likely that they have distinct functional properties (altered IL-10 secretion), which in turn affect the susceptibility to ACS development.

[Effects of acute decrease in preload on echocardiographic indices of systolic and diastolic function of the left ventricle in children with end-stage renal disease (ESRD). Comparative study before and after hemodialysis]. / Effets de la réduction de la précharge sur les paramètres échographiques de la fonction systolique et diastolique du ventricule gauche de l'enfant en insuffisance rénale terminale: étude comparative avant et après hémodialyse.

PURPOSE: Contrasting data exist about the hemodialysis induced changes of ventricular diastolic and systolic functions in adults. Few data in children with end-stage renal disease (ESRD) are reported. The aim of the present study was to evaluate the effect of a single hemodialysis (HD) session on left ventricular (LV) systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed tissue Doppler imaging (TDI) in hemodialysis children. METHODS: Thirty-five children with chronic renal failure (15 males, aged 12.8+/-3.8 years) on maintenance hemodialysis underwent conventional 2D and Doppler Echo together with measurement of longitudinal mitral annular motion velocities. Echocardiographic parameters were obtained 30 minutes before and 30 minutes after HD. Paired data were compared. RESULTS: Hemodialysis led to reduction in LV end-diastolic volume (p=0.001), end-systolic volume (p=0.05), left atrium area (p<0.0001), peak early (E wave) transmitral flow velocity (p=0.005), peak S velocity of pulmonary vein flow (p=0.002), aortic time velocity integral (p<0.0001) and aortic ejection time (p<0.0001). No significant change in Tei Index was observed after HD. Regarding TDI measures, velocities were not affected by preload reduction. Only the early diastolic velocities on the septal side of the mitral annulus decreased significantly (p=0.001) and the systolic velocities on the lateral side of the mitral annulus increased significantly (p=0.042) after hemodialysis. CONCLUSIONS: Most of Doppler-derived indices of diastolic function are preload-dependent. TDI velocities and Tei Index were not or minimally affected by preload reduction in hemodialysis children.

[Echocardiographic factors predictive of restoration and maintenance of sinus rhythm after reduction of atrial fibrillation]. / Facteurs échocardiographiques prédictifs du rétablissement et du maintien du rythme sinusal après réduction de la fibrillation auriculaire.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia. While the arrhythmia was initially thought to be little more than a nuisance, it is now clear that AF has a significant negative impact on quality of life and a corresponding increase in both morbidity and mortality. OBJECTIVE: The aim of this study was to identify Doppler echographic patterns that allow prediction of atrial fibrillation reduction and maintenance of sinus rhythm within 12 months. PATIENTS AND METHODS: One hundred and thirty patients having permanent atrial fibrillation, recent (51) or chronic (79) are included in the study, excepting those with valvular heart disease or thyroid dysfunction. The mean age was 63.5 +/- 11.3 years. Both transthoracic and transoesophageal echocardiography was performed using a Philips SONOS 5500 Echograph, before cardioversion. Were studied: end diastolic and systolic left ventricular diameters, left ventricular ejectionnal fraction, left atrial area (LAA), left atrial diameter, left atrial appendage area and peak emptying velocities of the left atrial appendage (PeV). Sinus rhythm was re-established in 102 patients (44 having recent and 58 chronic atrial fibrillation). Sinus rhythm was maintained for 12 months in 79 patients. RESULTS: Within the echographic parameters studied, the left atrial area (LAA) and peak emptying velocities of left atrial appendage (PeV) before cardioversion were the best predictors of restoration of sinus rhythm. On monovariate analysis, SOG is significantly lower and PicV is significantly higher in patients whose sinus rhythm had been restored in comparison with those with permanent atrial fibrillation. (Mean SOG: 27.7 +/- 7.62 vs. 34 +/- 7,6 cm2, p<0.0001; Mean PicV: 44 +/- 15.8 vs. 31.4 +/- 13,7 cm/s, p<0.0001). This difference was maintained on multivariate analysis (p=0.002 for SOG and p=0.005 for PicV). In patients with recent atrial fibrillation, only left atrial area can predict on mono and multivariate analysis (p=0.05, OR=0.5, IC=0.36 à 3.56), re-establishing of sinus rhythm whereas in patients with chronic atrial fibrillation, peak emptying velocity of left atrial appendage predict better re-establishing of sinus rhythm (p=0.04, OR=1.29, IC=0.12 à 4.23). The threshold values of LAA and PeV for conversion of atrial fibrillation into sinus rhythm are respectively 25 cm2 and 20 cm/sec. In patients who converted into sinus rhythm; LAA predict maintenance of sinus rhythm at the end of 12 months of survey (p=0.04) with a threshold value of 25 cm2. In the subgroup of patients admitted with chronic atrial fibrillation, PeV predicts better the maintenance of sinus rhythm (p=0.05) with a threshold value of 60 cm/sec, p=0.06; whereas LAA remains better in patients with a recent atrial fibrillation. (p=0.02). CONCLUSION: In addition to the anatomic study of cardiac structure and the search of intracavitary thromboses before reduction of atrial fibrillation, echocardiography allows prediction of cardioversion success (LAA and PeV) and maintenance of sinus rhythm within 12 months.

[Brucella endocardititis: clinical particularities and therapeutic modalities]. / Endocardite brucellienne: particularités cliniques et modalités thérapeutiques.

Brucella infective endocarditis is an uncommon, but serious complication of brucellosis. The aortic valve is the most commonly affected cardiac valve. Due to characteristics of the infection, medical therapy alone is not sufficient in treating the disease and best results are obtained with surgery combination. We describe a case of Brucella endocarditis involving the aortic valve suspected in front of the clinical data and the results of serology, confirmed by the culture of the native valves. In association with the medical treatment, management valve replacement lead to a favorable medium-term evolution.

[Predictive value of the markers of inflammation in acute coronary syndromes]. / Valeur prédictive des marqueurs de l'inflammation au cours des syndromes coronaires aigus.

This prospective study aims to establish the association between markers of inflammation (CRP and fibrinogen) and the severity of coronary lesions in patients with acute coronary syndromes. For this purpose, Plasma CRP, fibrinogen and troponin I were measured upon admission in 143 consecutive patients presenting with an acute coronary syndrome who underwent subsequently coronarography . Mean age is 55.5+/-11.6 years. Sex Ratio is 3.61 in favour of men; 68% of our patients presented with acute myocardial infarction with ST segment elevation; 23% with an unstable angina and 9% with an acute myocardial infarction without ST segment elevation. 31 patients (24.4%) have not any significant coronary lesion. Mean CRP level in these patients is (6.82+/-8.2 mg/l) lower than that measured in patients with significant lesions (17.4+/-26.9 mg/l; p=0.02). In patients with pathologic coronarogram, we demonstrated that the mean CRP level is higher in patients heaving one or more lesion of at least 70% of diameter stenosis than that in patients with no significant lesions (21.28+/-30.45 mg/l vs 11+/-14.2 mg/l; p=0.05). The mean CRP level grows with the number of proximal and significant stenoses. (CRP level in patients with one significant stenosis: 11+/-14.2 mg/l vs 27.45+/-39.67 mg/l in patients heaving 3 lesions; p=0.02. CRP level in patients with one proximal lesion: 14.35+/-19.8 mg/l vs 50.33+/-65 mg/l in patients heaving 3 proximal lesions; p=0.007). Fibrinogen levels measured upon admission in patients having significant lesions are higher than those measured in patients with normal coronary arteries (4.7+/-1.81 mg/l vs 3.93+/-1.69 mg/l; p=0.02). Compared with that measured in patients having distal lesions, the fibrinogen level is higher in case of proximal and multiple coronary lesions. There is a significant gradual increase in fibrinogen levels with increasing of the number of proximal coronary lesions and the degree of diameter stenosis. Multivariate logistic regression analysis showed that a CRP level higher than 10 mg/l is an independent predictive factor of the presence of the presence of significant coronary lesions (p=0.006; OR = 8.62; CI=0.7 to 7.4). We conclude that high CRP and fibrinogen plasma levels are associated with extended, severe and proximal coronary lesions.

[Doppler echocardiographic study of left ventricular diastolic function in hemodialysis patients]. / Etude échocardiographique de la fonction diastolique ventriculaire gauche chez les insuffisants rénaux hémodialysés.

OBJECTIVES: The purpose of this study is to examine the diastolic dysfunction particularities in hemodialysis patients and to identify the parameters having the most discriminating power of diastolic dysfunction. METHODS: Conventional Doppler echocardiography study implies left ventricular diastolic function from Doppler transmitral flow (E/A), color M-mode flow propagation velocity (Vp) and combined indexes: ratio of peak E-wave velocity to Vp (ENp) and difference in duration of pulmonary venous and mitral flow at atrial contraction (Ap-Am). RESULTS: Left ventricular diastolic dysfunction is found in 86% of the 100 hemodialysis patients: abnormal relaxation pattern 52%, pseudo-normal pattern 21%, restrictive pattern 13%. Left ventricular hypertrophy is independent of blood pressure (eta2=3.386; p>0.06). Diastolic function pattern has no relation with duration of dialysis treatment (F=2.637, p>0.05) or left ventricular mass (F=4.298, p>0.06). We noted correlations with age for all parameters of transmitral Doppler flow (p<0.01), Vp and systolic fraction except combined indexes (p>0.05). Doppler parameters of which discriminating power is significant (p<0.001) are in deceasing order: isovolumic relaxation time, E/A, Vp, early filling deceleration time, Ap-Am, E/VP and systolic fraction. The parameter Vp discriminates normal filling from abnormal or pseudo-normal patterns. However it doesn't allow any discrimination between abnormal and pseudo-normal patterns or abnormal and restrictive patterns. Discriminating analysis classify correctly 100% of pseudo normal pattern patients with 2 variables (isovolumic relaxation time and Vp or VP with E/Vp). Factor analysis suggests that Vp characterizes normal pattern and E/A ratio and Ap-Am characterize restrictive pattern. CONCLUSION: Parameters of diastolic function discriminating value is different from one stage to another. VP characterizes normal pattern, combined indexes restrictive pattern. Vp and isovolumic relaxation time discriminates normal from pseudo-normal pattern.

[Predictive value of aortic atherosclerosis detected by transoesophageal echocardiography for the presumption of coronary artery disease]. / Valeur prédictive de l'athérosclérose aortique détectée par l'échocardiographie transoesophagienne dans la présomption de l'athérosclérose coronaire.

The aim of this study was to determine the relationship between plaques of aortic atheroma detected by transoesophageal echocardiography and the condition of the coronary arteries at coronary angiography. Two hundred and seventeen consecutive patients were included for systematic transoesophageal echocardiography blinded to the results of coronary angiography. Significant coronary disease was defined as stenosis of at least 70% of the artery lumen. Aortic atherosclerosis was classified in four grades. The average age of the patients was 54.5 +/- 10.5 years. The sex ratio was 2.55 in favour of men. The average coronary score was 5 +/- 4.5 and the lesion index was 1.1 +/- 0.96. One hundred and fifty-nine patients had aortic atheroma, 73% of which (80 cases) were complex lesions. The descending aorta was the commonest site (91%) followed by the transverse (40% and ascending aorta (14%). When the ascending aorta was affected there was a very significant association with coronary artery disease (100% of cases). Sixty-one per cent of patients had lesions of one aortic segment, 28% had lesions of two aortic segments and in 10%, all three aortic segments were involved. The presence of aortic atheroma was correlated with coronary artery disease with a sensitivity and specificity of 86% and 76% respectively. The positive and negative predictive values were 81% and 31% respectively. Seventy-five per cent of patients with a coronary score of at least 7 had aortic atheroma with complex lesions in 47% of cases. The lesion index was significantly higher in this group when the coronary score was less than 7 (1.98 +/- 0.8 vs 0.65 +/- 0.7, p<0.00001). Patients with coronary artery disease have more complex lesions of the descending than of the ascending aorta (94 vs 25%). Significant coronary artery disease was correlated with the presence of aortic atheroma, especially of the ascending aorta. The specificity and positive predictive values were 100% but the negative predictive value was poor, irrespective of the aortic segment involved (32% for the ascending aorta, 36% for the transverse and 35% for the descending aorta). The authors conclude that transoesophageal echocardiography of the thoracic aorta is a good method of predicting severe coronary atherosclerotic disease.

[Thoracic ectopia cordis with tetralogy of fallot]. / Ectopia cordis thoracique associe a une tetralogie de Fallot.

Ectopia cordis; very rare congenital malformation, characterized by an evisceration of the heart through a parietal defect. The thoracic localization is most frequent. We report the case of a full term baby girl without follow-up of the pregnancy, presenting a beating mass in thoracic position, expansive to the effort, covered by a translucent membrane corresponding to an ectopique position of the heart. Transthoracic echocardiography shows cardiac malformation: Fallot tetralogy. The precocious diagnosis is possible by prenatal ultrasound examination after 12th week of pregnancy. The surgical treatment remain the only hope for these neonates. It's results depends on the associated malformations and the neonatal complications especially the infections. The prognosis remains poor in spite of the progress of surgical techniques.

[Diastolic heart failure--echocardiographic aspects]. / Insuffisance cardiaque diastolique--aspects echocardiographiques.

Diastolic function of the heart is a complex sequence of multiple interrelated events, and it has been difficult to understand, diagnose and treat the various abnormalities of diastolic filling that occur in patients with heart disease. Doppler is used to examine the different diastolic filling patterns of left ventricle. This concept can be applied clinically to estimate left ventricular filling pressures and to predict prognosis in selected groups of patients. This review presents a simplified approach to understanding the process of diastolic filling of the left ventricle and interpreting the Doppler flow velocity curves as they relate to this process.