[Subacute infectious endocarditis due to the agent of cat scratch fever: Bartonella henselae]. / Endocardite infectieuse subaiguë due à l'agent de la maladie des griffes du chat: Bartonella henselae.

The diagnosis of severe mitral stenosis with left atrial thrombus was rectified at valvular replacement in a 48-year old immuno-competent man who was a cat owner. The mass in the left atrium was, in fact, a large endocarditic vegetation. Pre- and postoperative blood cultures were negative as was culture of the excised mitral valve. The diagnosis of infectious endocarditis (IE) due to Bartonella Henselae was made from a positive serological test (1600) and identification of the germ by genetic amplification. Antibiotic therapy was continued for 6 months and the patient was cured with a follow-up of 4 years. Bartonella Henselae IE is very rare (14 reported cases) and affects mainly the aortic valve, often giving rise to very large vegetations which, in half the cases, are complicated by systemic emboli. Germs like Batonella are sensitive to most antibiotics, especially the aminosides and macrolides. In Bartonella Henselae IE, valve replacement is the rule (13 out of 14 cases) and the prognosis is usually good. Sero-diagnosis of Bartonellosis should be part of the systematic investigation of all blood culture negative IE.

Unfractionated heparin, time for a change?

BACKGROUND: In Ireland physician transfer to utilisation of Low Molecular Weight Heparin for Venous Thromboembolism has been slow, despite evidence of efficacy and concern about the level of anticoagulation achieved with Unfractionated Heparin. OBJECTIVE: To examine the effectiveness of Unfractionated Heparin administration in a teaching hospital in Ireland. Primary outcomes measured were time to therapeutic APTT and length of hospital stay. METHODS: We identified 50 consecutive eligible patients treated with continuous intravenous unfractionated heparin for Venous Thromboembolism from the period August 1994 to December 1996 at Beaumont Hospital, Dublin, Ireland. Data analysed included length of hospital stay, costing data and anticoagulation parameters (time to therapeutic APTT, percentage of time within therapeutic range, number of diagnostic tests, heparin dosages). RESULTS: A significant number of patients (22%) never achieved therapeutic APTT levels. Of those who did achieve therapeutic APTT levels at some time during their therapy, therapeutic range APTT was maintained only 28% of the time on heparin. 57% of the time results were below therapeutic while 15% of the time results were above therapeutic. Also 26% of the patients were discharged with INR results outside the therapeutic range despite an average length of stay of 13.3 days (over twice the ideal of 6 days). Ineffective anticoagulation influenced hospital length of stay in 60% of cases in our evaluation. Average cost of treatment with Unfractionated Heparin was 5897.86 Pounds versus the projected cost of Low Molecular Weight Heparin at 2562.78 Pounds for 6 days of in-patient therapy or 60.78 Pounds for outpatient therapy (excluding physician visit costs). CONCLUSIONS: Unfractionated Heparin therapy as reviewed in our study is sub-optimal with inadequate anti coagulation and prolonged hospitalisation. Low Molecular Weight heparin, with comparable therapeutic effect documented elsewhere, overall may cost less.

[Communication between the left ventricle and the right atrium in infectious endocarditis. Diagnosis using Doppler-echocardiography]. / Communication entre le ventricule gauche et l'oreillette droite au cours d'une endocardite infectieuse. Diagnostic par l'échocardiogramme-doppler.

The diagnosis of a communication between the left ventricle and right atrium was made by transthoracic and transoesophageal echocardiography in a 67 year old man with a recurrence of a methicillin-resistant staphylococcus aureus infectious endocarditis complicating aortic valve replacement with a bioprosthesis seven weeks previously. This diagnosis was confirmed at surgery; the left ventricular-right atrial communication was closed by suturing its edges and a new aortic valve prosthesis was implanted. Unfortunately, the patient died 4 months later of myocardial dysfunction although the infectious endocarditis seemed to have been sterilised by antibiotic therapy. Doppler echocardiography, especially using the transoesophageal approach is the best diagnostic method for rare complications of infectious endocarditis, usually of the aortic valve, the prognosis of which is improved by early surgery and appropriate antibiotic therapy for the causal organisms.

[Value of mass dosage of the MB isoenzyme of creatinine phosphokinase in the diagnosis of recent myocardial infarction]. / Intérêt du dosage pondéral de l'iso-enzyme MB de la créatine phosphokinase pour le diagnostic de l'infarctus du myocarde récent.

In 391 patients admitted 3.7 hours (h) (median) after experiencing infarct-like pain, kinetic monitoring of CK-MB "mass" (threshold: 7 micrograms/l), myoglobin (threshold: 90 micrograms/l) and total CK (threshold: 290 micrograms/l) was carried out at the time of admission and after 1.5, 3, 6, 9, 12, 24 and 48 h. When myocardial infarction (MI) was treated conventionally (102 patients). CK-MB peaked 11 h (median) after the onset of pain, later than myoglobin (9 h), but before total CK (12 h). The peak of the markers was higher in Q+ than in Q-MI (p < 0.05). When MI was treated by thrombolytic medications (44 patients), the increases in CK-MB, myoglobin and total CK were larger, and occurred sooner (peaks 9, 6 and 6 h, after the onset of pain respectively), but did not last as long. In 245 patients who had not had MI (including 123 with spontaneous angina), the levels of the three markers remained stable and well below the decision thresholds. The sensitivities of CK-MB, myoglobin and total CK were respectively 47.1, 51.8 and 34.8% at the time of admission, 67.3, 82.7 and 57.1% after 3 h and 83.1, 76.9 and 88.9% after 6 h. The combined determination of CK-MB and of myoglobin had a higher sensitivity (67.7% at the time of admission, 84.9% after 1.5% and 88.2% after 3 h: but most of this gain was due to myoglobin. The specificity of the three markers and their diagnostic accuracy are comparable. In the course of recent MI, the kinetics of CK-MB mass are thus slower than those of myoglobin, but a little faster than those of total CK. The choice of the most effective biochemical marker depends upon the interval between onset of chest pain and hospitalization of the patient. Repetition of the determinations improves the diagnostic situation.

[Myocardial infarction in the elderly. Comparison between 2 groups of patients over 75 and under 65 years of age]. / L'infarctus myocardique du sujet âgé. Comparaison de deux groupes de malades âgés de 75 ans et plus et de 65 ans et moins.

To define the clinical characteristics, prognosis and treatment of myocardial infarction (MI) in the elderly, we retrospectively compared the files of 101 patients aged > or = 75 years (mean: 82 +/- 4 years) and of 120 others aged < or = 65 years (mean: 55 +/- 4.7 years). The figures corresponding to younger patients are presented in brackets. The elderly group included 60.4% women (5%: p < 0.001), 58.9% hypertensive subjects (38.3%: p = 0.005); 30.4% diabetics (11.7%: p = 0.0013) and 12.6% smokers (66.1%: p < 0.001); 20.8% of the elderly had a history of MI (10%: p = 0.002), 15.8% of arteriopathy of the lower limbs (8.3%: p = 0.001) and 6.9% of cerebrovascular accident (1.7%: p = 0.02). Elderly patients were admitted after an average of 26.6 hours (10.4 hours: p < 0.001). Only 56.4% (79.2%) reported typical MI pain, 22.8% (7.5%) had a painless form, 31.8% (4.2%) an initial left ventricular failure, 21.8% (7.5%) a global cardiac dysfunction and 20.8% (4.2%) a cardiogenic shock (p < 0.001 for all comparisons). 63.4% had an anterior MI (40.8%: p < 0.001), 40.6% a Q-form (29.6%: p = NS) and 22.2% an atrial fibrillation (0.8%: p < 0.001). Serum myoglobin and total CK concentrations were significantly lower in elderly subjects. 20.8% of them received beta-blockers (86.7%), 43.6% aspirin (80%), 14.6% oral anticoagulant (56.7%), but 63.4% were given diuretics (25.2%) and 31.7% digitalis alkaloids and positive inotropic drugs (6.7%) (p < 0.001 for all these comparisons). Heparin, nitrates, calcium channel blockers, ACE inhibitors and antiarrhythmics were prescribed as often regardless of age. Only 10 elderly patients (9.9%) were treated with thrombolytics (77: 65%: p < 0.001); 6 (5.9%) underwent coronary angiography (43: 35.8%: p < 0.001), 2 (2%) angioplasty (11: 9.2%) and one (1%) coronary bypass surgery (12: 10%). 35 elderly patients (34.7%) died while in hospital (5: 4.2%), 22 suddenly, 10 in cardiogenic shock and 3 due to arrhythmias. 38 cases (37.8%) of heart failure (21: 17.5%), 21 (20.8%) recurrences of coronary insufficiency (8: 6.7%) and 11 (10.9%) mechanical complications of MI (4: 3.3%) were also observed (p < 0.001 for all these comparisons). Due to lack of sufficient data, we could not define the status of the surviving patients discharged from hospital. The wider use of thrombolytics, angiography and angioplasty (coronary bypass surgery still having a heavy mortality and morbidity) is probably the best way to improve the prognosis of MI in the elderly.

[Ilio-femoral vein thrombosis treated with tissue plasminogen activator in a pregnant woman]. / Thrombose veineuse ilio-fémorale traitée par l'activateur tissulaire du plasminogène chez une femme enceinte.

A 27-year-old woman, after 31 weeks of amenorrhoea during her second pregnancy, developed a left external iliac and femoral deep vein thrombosis, confirmed by venous ultrasonography and magnetic resonance imaging. The infusion of tissue plasminogen activator (rt-PA: 1.2 mg/kg, i.e. 80 mg over 3 hours), on the 2nd day, allowed revascularization of the femoral junction, while the external iliac vein remained occluded. The patient did not develop pulmonary embolism or haemorrhage, particularly obstetric haemorrhage. The subsequent pregnancy was uneventful until delivery, six weeks later, of a normal child. Three years later, the patient has no sequelae of her deep vein thrombosis. When required by the patient's condition, it seems that rt-PA can be used to treat severe deep vein thrombosis during pregnancy, either isolated or complicated by pulmonary embolism. Very rigorous cardiological, obstetric and laboratory surveillance is essential. A sufficient dosage, identical to that used in clinical settings other than pregnancy and a brief treatment duration (2 to 3 hours) are probably more effective and more reliable than lower doses continued for several days. However, the risk of haemorrhage remains difficult to predict and its prognosis, especially foetal, is often very poor. A larger series of cases is therefore necessary before this drug can unreservedly recommended in pregnant women.