Association of peripheral neuropathy with circulating advanced glycation end products, soluble receptor for advanced glycation end products and other risk factors in patients with type 2 diabetes.

BACKGROUND: The pathogenesis of diabetic peripheral neuropathy remains uncertain and nonenzymatic glycoxidation is one of the contributing mechanisms. The aim of this study was to assess the respective relationship of diabetic peripheral neuropathy with glycoxidation, compared with other identified risk factors, in patients with type 2 diabetes. METHODS: We included 198 patients with type 2 diabetes and high risk for vascular complications. Circulating concentrations of three advanced glycation end products (carboxymethyllysine, methyl-glyoxal-hydroimidazolone-1, pentosidine) and of their soluble receptor (sRAGE) were measured. Peripheral neuropathy was assessed by the neuropathy disability score and by the monofilament test and defined as either an abnormal monofilament test and/or a neuropathy disability score ≥6. Multivariate regression analyses were performed adjusting for potential confounding factors for neuropathy: age, gender, diabetes duration, current smoking, systolic blood pressure, waist circumference, height, peripheral arterial occlusive disease, glycated haemoglobin, estimated glomerular filtration rate and lipid profile. RESULTS: Prevalence of peripheral neuropathy was 20.7%. sRAGE and carboxymethyllysine were independently and positively associated with the presence of peripheral neuropathy. No significant association was found between peripheral neuropathy and methyl-glyoxal-hydroimidazolone-1 or pentosidine. Waist circumference, height and peripheral arterial occlusive disease were independently associated with peripheral neuropathy. CONCLUSIONS: Carboxymethyllysine and sRAGE were independently associated with peripheral neuropathy in patients with type 2 diabetes. Although the conclusions are limited by the absence of a healthy control population, this study confirms the relationship between advanced glycoxidation and diabetic peripheral neuropathy, independently of other risk factors.

Influence of peripheral vascular calcification on efficiency of screening tests for peripheral arterial occlusive disease in diabetes--a cross-sectional study.

AIMS: Pulse palpation and ankle brachial index are recommended to screen for peripheral arterial occlusive disease in people with diabetes. However, vascular calcification can be associated with false negative tests (arteriopathy present despite normal screening tests). We therefore studied the impact of peripheral vascular calcification on the performance of these tests. METHODS: This cross-sectional study included 200 people with diabetes at high risk of cardiovascular disease. The main exclusion factor was an estimated glomerular filtration rate < 30 ml/min. Peripheral arterial occlusive disease was diagnosed by colour duplex ultrasonography and peripheral vascular calcification scored by computed tomography scan. We measured sensitivity, specificity, predictive values, accuracy and likelihood ratios of pulse palpation and ankle brachial index, and looked for the impact of calcification on false negative tests (arteriopathy present despite normal screening tests). RESULTS: Ankle brachial index alone had poor sensitivity and negative predictive value and high negative likelihood ratio. Pulse palpation had higher sensitivity and negative predictive value. An abnormal pulse palpation, defined by weak or missing pulses, combined with an abnormal ankle brachial index, had the highest sensitivity and negative predictive value (92.3 and 89.8%, respectively). Vascular calcification score was higher in patients with false negative tests, for both pulse palpation and ankle brachial index (P < 0.0001 for all). Ankle systolic blood pressure was higher in patients with false negative tests for pulse palpation (P = 0.004). CONCLUSIONS: Below-knee vascular calcification gave a high rate of false negative results for ankle brachial index. Refined pulse palpation combined with ankle brachial index remained the best strategy to screen for peripheral arteriopathy.

[Prevalence and severity of erectile dysfunction in a population with coronary insufficiency: monocentric study]. / Prévalence et sévérité de la dysfonction érectile dans une population d'insuffisants coronariens : étude monocentrique.

PURPOSE: To study prevalence and severity of erectile dysfunction (ED) in a population of men treated in emergency for a coronaropathy. MATERIAL: The files of 200 patients who underwent a coronarography in urgency before the 1st of January 2007 were reviewed retrospectively. The following data were collated: epidemiological data and detailed breakdown of affected coronary arteries. The following patients were excluded from the current study: age over 65, past history of prostate surgery or pelvic external beam radiation therapy. The international index of erectile function (IIEF-5) questionnaire was sent by regular mail. Patients were classified according to the severity of ED: "no ED" between 21 and 25 inclusive, "mild ED" less than 21, "moderate ED" less than 17 and "strong ED" less than 10. RESULTS: Overall, 78 patients were included with a median age of 58 years. Prevalence of DE was 0.82 and median length of evolution was 9 months before coronary syndrome. Forty-nine patients (62.8%) had an ED classified between moderate and strong. ED was significantly associated with the group of patients smoking more than 20 cigarettes a day for at least 10 years (N = 44; P = 0.01) and with the group of patients older than 60 years (N = 38; P = 0.02). There was an association between the severity of the coronary disease and an ED classified between moderate and strong (P = 0.03). CONCLUSION: This study corroborates the existence of a strong link between ED and coronary disease, notably in patients under 65 years of age. In addition, it seems that the severity of ED is directly related with the anatomical severity of coronary disease.

Compliance with and effectiveness of adaptive servoventilation versus continuous positive airway pressure in the treatment of Cheyne-Stokes respiration in heart failure over a six month period.

OBJECTIVE: To compare compliance with and effectiveness of adaptive servoventilation (ASV) versus continuous positive airway pressure (CPAP) in patients with the central sleep apnoea syndrome (CSA) with Cheyne-Stokes respiration (CSR) and with congestive heart failure in terms of the apnoea-hypopnoea index (AHI), quality of life, and left ventricular ejection fraction (LVEF) over six months. METHODS: 25 patients (age 28-80 years, New York Heart Association (NYHA) class II-IV) with stable congestive heart failure and CSA-CSR were randomly assigned to either CPAP or ASV. At inclusion, both groups were comparable for NYHA class, LVEF, medical treatment, body mass index, and CSA-CSR. RESULTS: Both ASV and CPAP decreased the AHI but, noticeably, only ASV completely corrected CSA-CSR, with AHI below 10/h. At three months, compliance was comparable between ASV and CPAP; however, at six months compliance with CPAP was significantly less than with ASV. At six months, the improvement in quality of life was higher with ASV and only ASV induced a significant increase in LVEF. CONCLUSION: These results suggest that patients with CSA-CSR may receive greater benefit from treatment with ASV than with CPAP.

[The long term (15 years) evolution after valvular replacement with mechanical prosthesis or bioprosthesis between the age of 60 and 70 years]. / Evolution à long terme (15 ans) après remplacement valvulaire par prothèse mécanique ou bioprothèse entre 60 et 70 ans.

OBJECTIVE: the aim of this study was to document the choice between prosthesis and bioprosthesis in cases of valvular replacement during the seventh decade of life. METHODS: a retrospective and cooperative study linking eleven cardiac surgical teams and five medical cardiology teams combined 497 subjects born between 1915 and 1925 (average age 64.4 years) who underwent aortic (313 cases) or mitral (184 cases) valvular replacement with mechanical prosthesis (259 cases) or bioprosthesis (238 cases). Information was collected at each centre during the year 2000 on the long term evolution (going back 15 years), in particular on the mortality, non-fatal complications linked to the valve, cardiac complications and extra-cardiac events. These results were subjected to statistical analysis. RESULTS: the operative mortality of this group was 4.8%. The 15 year survival was 46% for the aortic mechanical prostheses, 32% for the aortic bioprostheses (p=0.04). 34% for the mitral bioprostheses and 33% for the mitral mechanical prostheses. Events linked to the valve were more frequent for the mitral valvulopathies than for the aortic valves (49% vs 26%, p<0.001). The absence of events linked to the valve at 15 years was 69% for the aortic mechanical prostheses and 68% for the aortic bioprostheses. This was the case in only 57% of mitral mechanical prostheses and 36% of the mitral bioprostheses (p=0.11). Thromboembolic accidents were three times more frequent in the mitrals than in the aortics (11.5 vs 3.8%, p=0.002). Haemorrhage was four times more frequent for the mechanical prostheses than for the bioprostheses (7.7 vs 2%, p=0.01). The risk of degeneration for the aortic bioprostheses was 20% at 15 years, three times less so after 65 years of age (p=0.03). At 48% it was much higher in the mitral valves at 15 years with no significant difference before and after 65 years of age (p=0.3). CONCLUSION: the current life expectancy of subjects in their seventh decade is important. The greatly elevated risk of bioprosthesis degeneration in the mitral position does not allow this alternative to be advocated before 70 years of age. In the aortic position, this risk is elevated before 65 years of age. It is lower after 65 years old. Nevertheless, this means the risk of reoperation in certain octogenarians must be accepted, balanced with the linear risk of haemorrhagic accidents for which a future reduction is expected thanks to milder anticoagulation for aortic mechanical prostheses and anticoagulation autocontrol.

[An exceptional etiology of left ventricular aneurysm: type AA amyloidosis]. / Une cause exceptionnelle d'anévrisme du ventricule gauche: l'amylose de type AA.

Left ventricular aneurysms most often occur in the course of myocardial infarction. In rare cases they can be detected when the coronary network is devoid of any lesions. The aetiology is therefore multiple and dependent on the context. One aetiology seems less exceptional and concerns idiopathic aneurysms encountered in the African population, where the role of a "debilitating condition" such as tuberculosis has been evoked. We report the case history of a young patient from Zaire with a left ventricular aneurysm discovered in association with ganglionic tuberculosis complicated by AA amyloidosis. Histological analysis allowed the aetiological diagnosis to be established. Aneurysmal dilatation of the left ventricle was reported in the presence of amyloid deposits at the intra-myocardial arteriole level, whereas the context suggested a tubercular role. In spite of the difficulty of establishing a precise aetiological diagnosis, there seems to exist a consensus for surgical management.

[The best of valvular heart disease in 2002]. / L'essentiel de 2002 des valvulopathies.

For AS, besides a very thorough update by Carabello on their management, new experimental work confirms that the pathophysiology of the condition is closer to atherosclerotic and inflammatory processes than pure degeneration. Moreover this year brings a batch of long term post-operative results, one of which is an important series relating to 2194 bioprostheses followed up for 15 years. The choice of valvular substitute between 60 and 70 years old is the subject for several studies. A series of 259 re-operations for bioprosthesis deterioration allows quantification of the operative risk to which those with this substitute are subjected in case of degeneration. Finally, the strategy to adopt in a patient with an indication for aortocoronary bypass but also with a not-tight AS is discussed (abstention, decalcification, or "preventive" valvular replacement?). For aortic insufficiency (AI) some new results for the Ross operation have been published and the first publications reporting on the attempts of experimental positioning of bioprostheses via the percutaneous route in animals are appearing. As for mitral valvulopathies, MI has carved a privileged place. Much work this year relates amongst other things to functional MI in dilated cardiomyopathies with dilatation of the ring, to the natural history of mitral valvular prolapse detailed in an important series of 833 patients, and to the evolutive risk of atrial fibrillation (AF) with MI and its treatment during plasty or mitral valvular replacement procedures. Anticoagulant treatment for mechanical prostheses is the subject of much work drawn from a large German prospective study (GELIA) confirming the general tendency for alleviation of intensity in aortic especially but also mitral valvulopathies, stressing the advantages of autocontrol. Finally, the Valvulopathy Working Group of the European Society of Cardiology publishes its recommendations for asymptomatic valvulopathies, recalling the echographic criteria of dilatation and left ventricular function to be retained for operative indications, emphasising furthermore the significance of the stress test in the follow up of asymptomatic AS.

[The best of 2001. Valve diseases]. / L'essentiel de 2001 en valvulopathies.

The publications in 2001 regarding valvulopathies have concerned all sectors of this pathology. Aortic valvulopathies are the object of new work supporting the relationship between aortic sclerosis or stenosis and cardiovascular risk factors. They confirm the analogy between lesions of inflammatory origin observed on calcified valves and atherosclerotic plaques (Mohlner). They find higher rates of serum lipids in the case of valvular replacement for stenosis than for aortic insufficiency albeit in an older population (Novaro). Monin shows the possibility of a better pre-operative prognostic approach for advanced aortic stenoses at low transvalvular gradient with left ventricular dysfunction, for which the post-operative results are better when low dose stress echocardiography has shown the existence of a contractile reserve. For the results of aortic surgery with biological prostheses it is widely reported that they behave as homografts (O'Brien), stented heterografts (Puvimanasinghe) or stent-less (Hubaut). A controversy exists on the subject of the degenerative mechanism of bioprostheses between the supporters of the immunological hypothesis (Human) and those of the purely degenerative hypothesis (Mitchell). This controversy is far from being insignificant because the infectious or other risks run by patients with bioprostheses are conceivable with the addition of an immuno-suppressant treatment. Among the mitral valvulopathies, insufficiencies with an ischaemic origin have a harmful effect on the long term prognosis even for medium leaks (Grignoni). As for the method of repairing these ischaemic leaks, consensus has not been reached between the proponents of exclusive revascularisation, plasty or replacement (Mickleborough, Otsuji). The quality of the very long term results for mitral plasty by Carpentier's technique for rheumatic mitral insufficiency (Chauvaud) or non-rheumatic (Braunberger, Mohty) is confirmed, especially for the latter. Its feasibility by a minimally invasive approach is reported (Schroeyers). Anticoagulation for prostheses remains one of the challenges for valvular surgery. The addition of a platelet anti-aggregant is not accepted by all, due to the increased haemorrhagic risk. A meta-analysis of 2,199 operations seems in favour of this addition if the dose is weak (Massel). It's a question of an attitude having become normal practice across the Atlantic, but not in Europe (Englberger).

Immediate and mid-term results of repeat percutaneous mitral commissurotomy for restenosis following earlier percutaneous mitral commissurotomy.

AIMS: This study assessed the results of repeat percutaneous mitral commissurotomy for mitral restenosis following a first procedure. METHODS AND RESULTS: Repeat balloon commissurotomy was performed in 53 patients who had symptomatic restenosis a mean of 6+/-2 years (2-11) after a successful first procedure; seven patients had mildly calcified valves. All patients had restenosis with a fusion of both commissures as assessed by echocardiography. A double-balloon was used in one case and the Inoue technique in 52. Complications were stroke in one patient and severe mitral regurgitation (Sellers grade 3) in two. Valve area increased from 1.03+/-0.22 to 1.82+/-0.21 cm(2)(P<0.0001) as assessed by planimetry. Good immediate results, defined as valve area >/=1.5 cm(2)with no regurgitation >2/4, were obtained in 48 patients (91%). The 5-year survival rate without operation and in NYHA class I or II was 69+/-11% in the whole population, and 76+/-11% in the 48 patients who had had good immediate results. CONCLUSION: This study suggests that repeat balloon commissurotomy is a valid treatment for symptomatic restenosis after a first successful procedure. It gives good results in patients selected on the basis of favourable characteristics and the echocardiographic analysis of the mechanism of restenosis.

Late results of percutaneous mitral commissurotomy for calcific mitral stenosis.

The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p <0.0001), sinus rhythm (p = 0.0006), a smaller extent of calcium (p = 0.02), and a lower gradient after PMC (p <0.0001). Despite a frequent deterioration on follow-up after PMC for calcific mitral stenosis, the predictive analysis suggests that PMC may be useful in deferring surgery in selected patients with mild to moderate calcific deposits, who have otherwise favorable characteristics.

Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: late efficacy and implications for patient selection.

OBJECTIVES: The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy. BACKGROUND: Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy. METHODS: We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 +/- 8 years after surgical commissurotomy. Mean age was 47 +/- 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121. RESULTS: Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area > or =1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 +/- 5%, and 58 +/- 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model. CONCLUSIONS: Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

[The best of valvular heart disease in 1999]. / L'essentiel de 1999 dans les valvulopathies.

The year 1999 confirmed important changes in the clinical presentation, the methods of investigation and the treatment of valvular heart disease. The near disappearance of acute rheumatic fever in the developed world, associated with the increase in life expectancy has resulted in degenerative aetiologies becoming the most common causes of valvular heart disease with a dominance of aortic stenosis and mitral incompetence. The increase in average age of the operated patients explains the increasing role of comorbidity and the higher incidence of mixed (valvular and coronary artery) surgery. Doppler echocardiography is now the reference method of investigating valvular heart disease, both pre- and post-operatively (especially in mitral incompetence). The value of tri-dimensional echocardiography is beginning to be recognised. The technical advances in surgical techniques are also important, especially the extension of conservative methods both in mitral incompetence and parietal lesions of dystrophic aortic incompetence. The good long-term results of homograft aortic valves have been confirmed, especially in young patients and infectious endocarditis complicated by abscess. The Ross procedure is an interesting alternative in children and adolescents in the absence of available homografts. The persistence of good results in the long term has made percutaneous mitral commissurotomy the reference in mitral stenosis. The improvement in surgical and interventional methods has widened the operative indications which are now considered in patients who are pauci- or a-symptomatic.

[When is surgery needed for minimally symptomatic or asymptomatic acquired valvulopathy?]. / Quand opérer une valvulopathie acquise a ou pauci symptomatique?

GENERAL PRINCIPLES: The first step is to determine the absence or the minimal nature of the functional impairment from history taking and, for doubtful cases, with an exercise test. Therapeutic indications differ depending on the valvular lesion. AORTIC STENOSIS: Surgery is indicated only for severe aortic stenosis or in cases with a particular risk. Indications for surgery are: false asymptomatic patients with a positive exercise test, patients with abnormal hemodynamic and/or rhythm response to an exercise test (decrease in systolic pressure > 10 mmHg, severe ventricular arrhythmia), aortic stenosis with left ventricular ejection fraction < 50%, aortic stenosis associated with severe coronary artery disease amendable with bypass surgery. MITRAL STENOSIS: The advent of percutaneous mitral commissurotomy has totally changed the treatment of mitral stenosis. This new method can be proposed for stenotic but flexible mitral valves with no major lesion of the lower valvular apparatus or for more advanced valve disease with a risk of hemodynamic failure or thromboembolism. MITRAL INSUFFICIENCY: When mitral leakage is the only valvular defect, surgery is indicated if the volume regurgitated is important as assessed clinically and by echocardiography. Conservative surgery is preferred due to the low risk and the high probability of good long term outcome. Factors to take into account include: the experience of the surgical team in this field, the etiology of mitral insufficiency, the impact on the cardiac condition. Surgery should be performed before the development of atrial fibrillation, major cardiomegaly, left ventricular dilatation (end systolic diameter > 45 mm), or an alteration of the ejection fraction (< 60%). AORTIC INSUFFICIENCY: Cases of the aortic insufficiency should be differentiated according to the state of the ascending aorta. Annuloaortic ectasia requires surgery when the diameter reaches = 50-55 mm (depending on the authors). For valve dysplasia with non aneurysmal cylindrical dilatation of the ascending aorta, the indication for surgery depends on the progressive aggravation of the aortic dilatation. For cases with unique valve lesions, the indication for surgical repair of aortic insufficiency depends on the impact on the left ventricle. Indications for surgery include major radiographic cardiomegaly (cardio-thoracic ratio > 0.58), echocardiographic evidence of major left ventricular dilatation (end diastolic diameter > 75 mm and end systolic diameter > 55 mm), or an alteration of the systolic function (ejection fraction < 0.50 or 0.55). SPECIAL SITUATIONS: In disease states associating stenosis and insufficiency, valve replacement is often the only possibility. Careful patient selection is the rule. Surgery is often needed for cases with multiple valve involvement where different therapeutic options can be used for the different valves. The dominant lesion and the degree of heart dilatation and dysfunction guide decision making.

Late results of percutaneous mitral commissurotomy in a series of 1024 patients. Analysis of late clinical deterioration: frequency, anatomic findings, and predictive factors.

BACKGROUND: The optimal use of percutaneous mitral commissurotomy (PMC) in a wide range of patients requires accurate evaluation of late results and identification of their predictors. METHODS AND RESULTS: Late results of PMC were assessed in 1024 patients whose mean age was 49+/-14 years. Echocardiography showed that 141 patients (14%) had pliable valves and mild subvalvular disease, 569 (55%) had extensive subvalvular disease, and 314 (31%) had calcified valves. A single balloon was used in 26 patients, a double balloon in 390, and the Inoue Balloon in 608. Good immediate results were defined as valve area >/=1.5 cm2 without regurgitation >2/4 (Sellers' grade) and were obtained in 912 patients. Median duration of follow-up was 49 months. The 10-year actuarial rate of good functional results (survival with no cardiovascular death and no need for surgery or repeat dilatation and in New York Heart Association [NYHA] class I or II) was 56+/-4% in the entire population. Follow-up echocardiography was available in 90% of the patients who experienced poor functional results after good immediate results and showed restenosis in 97% of these. In multivariate analysis, the predictors of poor functional results were old age (P=0.0008), unfavorable valve anatomy (P=0.003), high NYHA class (P<0.0001), atrial fibrillation (P<0.0001), low valve area after PMC (P=0.001), high gradient after PMC (P<0.0001), and grade 2 mitral regurgitation after PMC (P=0.04). CONCLUSIONS: PMC can be performed with good late results in a variety of patient subsets. Prediction of late events is multifactorial. Knowledge of these predictors can improve patient selection and follow-up.

[Splenic involvement in infectious endocarditis. Association for the Study and Prevention of Infectious Endocarditis]. / Les atteintes spléniques au cours des endocardites infectieuses. Association pour l'étude et la prévention de l'endocardite infectieuse.

INTRODUCTION: Splenic involvement in the course of endocarditis consists in either splenic infarct or abscess. Pathophysiological examinations suggest the existence of a continuum between the two types of lesion. Signs and symptoms are usually poor or aspecific. Current incidence and diagnostic methods are rarely reported in recent medical literature. EXEGESIS: We report a retrospective study conducted from a questionnaire that was circulated to nine French medical units. Two hundred and twenty five patients with infectious endocarditis according to Duke university criteria were included in the study. The existence of splenic lesions was investigated in 153 patients (68%). Splenic involvement was documented in 35 patients. Diagnostic methods were: abdominal echography (n = 77), abdominal CT scan (n = 40), and both techniques (n = 36). The incidence of splenic lesions was 9%, 35% and 36%, respectively. Among patients investigated using both diagnostic techniques, splenic abnormalities were detected by CT scan in 13 cases and by echography in six cases. Splenic abscess was suspected in nine patients by combining suggestive clinical course and radiological abnormalities, but was definitively evidenced in only four patients (surgery, n = 2, post-mortem examination, n = 2) presenting with large lesions (> or = 8 cm) associated with aortic endocarditis. All other 26 cases were categorized as splenic infarcts; however, diagnosis was confirmed in only two cases (surgery n = 1, autopsy n = 1). CONCLUSION: These data suggest that: 1) the incidence of splenic involvement during endocarditis is approximately 35%, 2) CT scan is probably superior to echography for spleen screening, and 3) incidence of abscess requiring specific surgery is very low, inferior to 2%.

Perivalvular abscesses associated with endocarditis; clinical features and prognostic factors of overall survival in a series of 233 cases. Perivalvular Abscesses French Multicentre Study.

AIMS: The purposes of this study were to determine the clinical features and to identify prognostic factors of abscesses associated with infective endocarditis. METHODS AND RESULTS: During a 5-year period from January 1989, 233 patients with perivalvular abscesses associated with infective endocarditis were enrolled in a retrospective multicentre study. Of the patients, 213 received medical surgical therapy and 20 medical therapy alone. No causative microorganism could be identified in 31% of cases. Sensitivity for the detection of abscesses was 36 and 80%, respectively using transthoracic and transoesophageal echocardiography. Surgical treatment consisted of primary suture of the abscess (38%), insertion of a felt aortic or mitral ring using Teflon or pericardium (42%), or debridment of the abscess cavity (20%). The 1 month operative mortality was 16%. Actuarial rates for overall survival at 3 and 27 months in operated patients were 75 +/- 10% and 59 +/- 11%, respectively. Increasing patient age, staphylococcal infection, and fistulization of the abscess were found to be independent risk factors in both 1 month and overall operative mortality. Renal failure was a risk factor predictive of operative mortality at 1 month, whereas uncontrolled infection and circumferential abscess were regarded as risk factors predictive of overall operative mortality. CONCLUSION: The data determined prognostic factors of abscesses associated with infective endocarditis.

[Cardiac abscess in infectious endocarditis. A multicenter study apropos of 233 cases. The Working Group on Valvulopathy of the French Society of Cardiology]. / Abcès cardiaques dans l'endocardite infectieuse. Etude multicentrique à propos de 233 cas. Groupe de travail sur les valvulopathies de la Société française de cardiologie.

The aim of this retrospective multicenter study was to determine present characteristics of infectious endocarditis complicated by abscess and to identifying predictive factors of mortality. The files of 233 patients with infectious endocarditis complicated by perivalvular abscesses between January 1989 and December 1993 were analysed. Two hundred and thirteen patients underwent medico-surgical treatment (175 aortic and 38 mitral abscesses) and 20 patients underwent medical treatment alone (17 aortic and 3 mitral abscesses). The abscess was observed on native valves in 156 cases and valve prostheses in 77 cases. The causative organism was identified in 69% of cases : the commonest organism was the staphylococcus. The diagnostic sensitivity of transthoracic and transoesophageal echocardiography was 36 and 80% respectively. The operative mortality at one month was 16%. Patients over 65 years of age, staphylococcal infection, renal failure and fistulisation of the abscess, were identified as independent predictive factors of mortality at one month. The survival rate three months after surgery was 75 +/- 10% and 59 +/- 11% at 27 months. An age over 65, staphylococcal infection, uncontrolled infection, circumferential abscess and fistulisation were independent predictive factors of global mortality (the first month and after). The mortality rate in unoperated patients was 40%: cardiac failure and fistulisation of the abscess detected by echocardiography were predictive factors of mortality on univariate analysis.