Aortic dilatation: Value of echocardiography in the systematic assessment of elite rugby players in the French National Rugby League (LNR).

The value of echocardiography in the screening of athletes in addition to the electrocardiogram is debated and still unclear. 336 rugby players in French professional divisions (Top 14, Pro D2) were prospectively assessed with electrocardiogram and echocardiography. 75% were Caucasian, 16.4% Pacific Islanders, and 8.6% Afro-Caribbean. Six (1.8%) players had electrocardiogram abnormalities, exclusively negative T waves. Twenty-one (6.25%) of them had abnormal echocardiography findings: one possible early hypertrophic cardiomyopathy, one anomalous origin of coronary artery, two left ventricular dilatations, one isolated bicuspid aortic valve, two aortic regurgitations, and 14 ascending aortic dilatations. The median aortic diameter was modestly correlated with age: 32 mm [23-48] in players aged ≤25 years vs 33.5 mm [24-50] in those aged >25 years (P = 0.02, correlation coefficient -.01). This tendency increased with cumulative hours of weight training: 34 mm [24-50] in forwards vs 32 mm [25-44] in backs (P = 0.01); and ethnicity, with Pacific Islanders having higher values in both raw data and body surface area or height-indexed data than Afro-Caribbeans and Caucasians: 34 [25-50] vs 32 [27-48] and 33 [23-49] mm (P = 0.017); 15 [12.2-21] vs 14.8 [11-19.9] and 14.8 [10-20.9] mm/m2 (P < 0.0001); 18.5 [14-25] mm/m vs 17.4 [14.8-25] mm/m and 17.6 [12.2-25.3] mm/m (P = 0.0125). In a population of professional rugby players, echocardiography was contributive. The main anomaly was aortic dilatation (14/336, 4.2%). While this is proportionally much higher than in other sports, the cutoffs need to be defined more precisely by including the criterion of ethnicity, as is already the case for electrocardiography.

The medical value and cost-effectiveness of an exercise test for sport preparticipation evaluation in asymptomatic middle-aged white male and female athletes.

BACKGROUND: Cardiovascular events related to high-intensity sport practice are rare but dramatic. Coronary artery disease (CAD) is the leading cause of these events after the age of 35 years. The value of a maximal exercise test (ET) for detection of athletes at risk remains a matter of debate. AIM: The aim of this prospective multicentre study was to clarify the medical value and cost-effectiveness of an ET in middle-aged white asymptomatic athletes who participate in high-intensity sport. METHODS: All athletes had a physical examination, assessment of cardiovascular risk factors, a resting electrocardiogram and an ET. In case of abnormal ET, complementary cardiovascular evaluation was performed, when requested, to detect potential cardiovascular disease. RESULTS: 1361 asymptomatic athletes (mean age 50.4±9.6 years; mean training 5.1±3.2h/week; 10.4% women) with a normal resting electrocardiogram and without cardiovascular disease were consecutively included. An abnormal ET was reported in 144 subjects (94% men); this was positively related to the subject's age and cardiovascular risk level. Cardiac arrhythmias (48%) and CAD symptoms (33.3%) were mainly reported. Cardiovascular disease was confirmed in 24 cases (1.7% from the whole population; 16.7% from those with an abnormal ET) - mainly CAD (n=12) and arterial hypertension (n=8). Seventy athletes presented significant unexplained arrhythmias. The cost was approximately €8450 for every confirmed case of cardiovascular disease. CONCLUSIONS: In this multicentre study in middle-aged athletes, a systematic ET was abnormal in 10.6% of cases. About 2% of subjects had cardiovascular disease, mainly arrhythmias and CAD. From these results, it seems that in a trained population aged >35 years, ET should be targeted at men with at least two cardiovascular risk factors, with acceptable cost-effectiveness.

Fast track echo of abdominal aortic aneurysm using a real pocket-ultrasound device at bedside.

BACKGROUND: Ultraminiaturization of echographic systems extraordinarily provides the image "within" the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines' cost-effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches. METHODS: A first step of this study was to validate the VSCAN's image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination. RESULTS: A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97-0.99, P < 0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P < 0.05) and hypertensive (88.8% vs. 56.9%, P < 0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department. CONCLUSION: Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients.

Validation of the smallest pocket echoscopic device's diagnostic capabilities in heart investigation.

We hypothesized that, based on greyscale imaging and color Doppler capabilities, a new pocket ultrasound device (PUD) could accurately record cardiologic diagnostic findings. One hundred patients referred for conventional clinical indications underwent a standard echocardiography. Subsequently, a second physician blinded to the results performed an evaluation using the PUD on the same patients. Study end-points were echocardiographic window quality; left ventricular (LV) morphology; function; hypertrophy; right ventricular, atrial and vena caval morphologies; aortic and mitral valvulopathies; and pericardial structure. Using a scale of three grades, concordance in image quality proved good with a kappa coefficient (κ) of 0.71. Concordances between systems were excellent for LV function and morphology (κ = 0.91 and 0.96). Concordance for LV hypertrophy was good (κ = 0.74). Concordances for mitral regurgitation grades were 0.90, 0.95 and 1.00, respectively. In conclusion, a new PUD enabled scanning examinations, which showed good concordance of basic and qualitative diagnostic capability to standard echocardiographic instruments.

Validation of a new bedside echoscopic heart examination resulting in an improvement in echo-lab workflow.

BACKGROUND: In daily cardiology practice, porters are usually required to transfer inpatients who need an echocardiogram to the echocardiographic department (echo-lab). AIMS: To assess echo-lab personnel workflow and patient transfer delay by comparing the use of a new, ultraportable, echoscopic, pocket-sized device at the bedside with patient transfer to the echo-lab for conventional transthoracic echocardiography, in patients needing pericardial control after cardiac invasive procedures. METHODS: After validation of echoscopic capabilities for pericardial effusion, left ventricular function and mitral regurgitation grade compared with conventional echocardiography, we evaluated echo-lab personnel workflow and time to perform bedside echoscopy for pericardial control evaluation after invasive cardiac procedures. This strategy was compared with conventional evaluation at the echo-lab, in terms of personnel workflow, and patients' transfer, waiting and examination times. RESULTS: Concordance between echoscopy and conventional echocardiography for evaluation of pericardial effusion was good (0.97; kappa value 0.86). For left ventricular systolic function and mitral regurgitation evaluations, concordances were 0.96 (kappa value 0.90) and 0.96 (kappa value 0.86), respectively. In the second part of the study, the mean total time required in the bedside echoscopy group was 20.3±5.4 mins vs. 66.0±16.4 mins in the conventional echo-lab group (p<0.001). The echo-lab strategy needed porters in 100% of cases; 69% of patients needed a wheelchair. CONCLUSION: The use of miniaturized echoscopic tools for pericardial control after invasive cardiac procedures was feasible and accurate, allowing improvement in echo-lab workflow and avoiding patient waiting time and transfer.

Global longitudinal strain as a major predictor of cardiac events in patients with depressed left ventricular function: a multicenter study.

BACKGROUND: The risk stratification of patients with left ventricular (LV) dysfunction can be performed using echocardiographic parameters such as the ejection fraction (EF). Recently, new technologies based on deformation measurements have been shown to identify early myocardial dysfunction before EF decrease. Consequently, tools such as two-dimensional strain have been incorporated into echocardiographic systems, allowing for fast, reliable, and reproducible calculation of longitudinal components of LV systolic deformation. The hypothesis in this study was that as a more sensitive marker of LV dysfunction, longitudinal strain would allow for the risk stratification of patients with heart failure. METHODS: This multicenter study included 147 patients with heart failure with LV EFs ≤ 45% (mean age, 64 ± 14 years; 74% men; mean LV EF, 29.9 ± 8.9%). Conventional echocardiographic parameters as well as global and segmental longitudinal strain were measured and compared with these values in a control population. Patients were monitored for cardiac events, defined as a composite criterion, over 12 months. RESULTS: Clinical events were observed in 20% of patients during the 12-month follow-up period. On receiver operating characteristic curve analysis, global longitudinal strain had the highest prognostic value (area under the curve, 0.83) and the highest combination of sensitivity (73%) and specificity (83%), using a cutoff value of -7%. CONCLUSION: Strain assessment is highly feasible and reliable in patients with LV dysfunction and allows for cardiovascular risk stratification in patients with heart failure with greater accuracy than LV EF.

Systolic time intervals as simple echocardiographic parameters of left ventricular systolic performance: correlation with ejection fraction and longitudinal two-dimensional strain.

AIMS: Conventionally, the evaluation of left ventricular (LV) systolic function is based on ejection fraction assessment, which may be supplemented by other echocardiographic techniques, such as tissue Doppler imaging, 3D evaluation, and speckle tracking strains. However, these imaging modalities have a high technicity and are time-consuming, while being associated with reproducibility limitations. In this context, the usefulness of simpler measurements such as systolic time intervals (STI) by pulsed Doppler echocardiography must be emphasized. METHODS AND RESULTS: In this multicentre study, left ventricular ejection fraction (LVEF), dP/dt(max), LV stroke volume, myocardial longitudinal deformation, aortic pre-ejectional period (PEP, ms), and left ventricular ejection time (LVET, ms) were prospectively investigated and compared in 134 consecutive heart failure (HF) patients and 43 control subjects. Feasibility of STI measurements was 100%. Intra-observer reproducibility was 98% for PEP, 96% for LVET, 87% for LVEF, and 93% for global longitudinal strain (GLS). By subgroup analyses, with increasingly altered LVEF or GLS, PEP significantly increased, whereas significantly LVET decreased, resulting in a significantly increased PEP/LVET ratio (P < 0.001). In the HF patients group, a correlation between LVEF and PEP/LVET was found, with r = 0.55 (y = -0.0083x + 0.75, P < 0.001). Based on receiver operating curve analyses, the area under the curve was 0.91 for PEP/LVET > 0.43, which allowed us to detect LVEF < 35% with a sensitivity of 87%, and a specificity of 84%. CONCLUSION: STI can be easily and accurately measured in clinical practice, and may be used for detecting alterations in LV systolic function. Moreover, this method is likely to have potential applications in the management of HF patients.

Identification and characterization of super-responders after cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) has been shown to induce a spectacular effect on left ventricular (LV) function in certain patients. Our aim was to analyze and characterize the super-responders (SRs) to CRT using echocardiography in 186 patients with a conventional indication according to the European Society Cardiology guidelines. The investigation took place before and 6 months after implantation. CRT-SRs were defined by an improvement of the New York Heart Association functional class and LV ejection fraction to > or = 50% in absolute values associated with a relative LV end-systolic volume reduction of > or = 15%. Of the 186 patients, 18 (9.7%) were identified as CRT-SRs and had a significantly lower prevalence of ischemic etiology (11%), lower LV dimensions, lower left atrial volume, and greater global longitudinal strain at baseline. Receiver operating characteristics curves identified global longitudinal strain as the strongest parameter for predicting CRT-SRs, with a cutoff value of -12% (area under the curve 0.87, sensitivity 71%, and specificity 85%, p <0.01). In conclusion, in the present retrospective study, only a left atrial volume <55 ml and global longitudinal strain < or = -12% were independent predictors of CRT-SRs.

[Management of the prosthetic heart valve patient in clinical practice]. / Surveillance d'un patient porteur d'une prothèse valvulaire.

In use since 1961, valvular prostheses allow the correction of the severe valvular diseases when conservatrice procedures are not possible. Current prostheses have outstanding haemodynamic features. Mechanical prostheses have a supposedly unlimited life span but require anticoagulant treatment. Bioprostheses do not need such treatment but end up to deteriorate and need reoperation. Both can be affected by valve-related complications (thromboembolic events, endocarditis, deterioration, desinsertion...): an ideal prosthesis does not exist yet. All patients with valvular prosthesis require close follow-up, where echocardiography holds preeminent place.

Validation of an echocardiographic multiparametric strategy to increase responders patients after cardiac resynchronization: a multicentre study.

AIMS: We sought to develop and validate a multiparametric algorithm by applying previously validated criteria to predict cardiac resynchronization therapy (CRT) response in a multicentre study. Thirty per cent of patients treated by CRT fail to respond to the treatment. Although dyssynchrony by echocardiography has been used to improve the selection of patients, the complexity of myocardial contraction has generated a moderate improvement using any of several individual parameters. METHODS AND RESULTS: Two hundred end-stage heart failure patients [NYHA 3-4 and left ventricular ejection fraction (LVEF)<35%] with QRS>120 ms were included. Echocardiography analysis focused on the following parameters: atrioventricular dyssynchrony, interventricular dyssynchrony, and intraventricular dyssynchrony that integrated radial (PSAX M-mode) and longitudinal [tissue Doppler imaging (TDI)] evaluations for spatial (wall to wall) and temporal (wall end-systole to mitral valve opening) dyssynchrony diagnosis. Following CRT implantation, patients were monitored for 6 months with functional and echo evaluations defining responders by a 15% reduction in end-systolic volume. Mean QRS duration and LVEF were 152 +/- 17 ms and 25 +/- 8%. There was a CRT response in 57% of patients, independent of QRS width. Mean prevalence of positive criteria was 34 +/- 8%. Feasibility and variability averages were 81 +/- 20% and 9 +/- 4%. In a single parametric approach, ranges of sensitivities and specificities were 18-65% and 45-84% with a mean of 41% and 66%. A multiparametric approach by focusing on criteria combination decreased the mean rate of false-positive results to 14 +/- 12%, 5 +/- 4%, 2 +/- 2%, and 1 +/- 2% from one to four parameters, respectively. More than three parameters were associated with a specificity above 90% and a positive predictive value above 65%. Reproducibility of this global strategy was 91%. CONCLUSION: A multiparametric echocardiographic strategy based on the association of conventional criteria is a better indicator of CRT response than the existing single parametric approaches.

Effect of catheter ablation for isolated paroxysmal atrial fibrillation on longitudinal and circumferential left ventricular systolic function.

Isolated paroxysmal atrial fibrillation (AF) is commonly associated with left ventricular (LV) diastolic dysfunction but normal radial systolic contraction. We aim to investigate LV systolic function more precisely using 2-dimensional strain technique in patients with isolated paroxysmal AF and to evaluate evolution of longitudinal, circumferential, and radial (or transverse) strain components after catheter ablation of AF. Thirty patients with isolated paroxysmal AF were investigated by echocardiographic studies before and at 1-day, 1-month, 6-month, and 12-month intervals after radiofrequency ablation. Left heart dimensions and LV systolic and diastolic functions were evaluated at each time interval. LV systolic function was quantified by LV ejection fraction and by 2-dimensional strain evaluation, giving regional and global longitudinal, circumferential, transverse, and radial peak of percentage deformation. Patients with AF were compared with 30 control subjects, paired by age and by sex. Before AF ablation, LV ejection fraction, transverse and radial strains were not significantly different from control subjects. By contrast, global longitudinal and circumferential strains were significantly lower than controls (-17.7%+/-2.4% vs -21.5%+/-2.0% [p<0.01] and -16.0%+/-2.9% vs -20.7%+/-3.4% [p<0.01], respectively). At the end of follow-up, global longitudinal and circumferential strains were significantly improved (-20.8%+/-2.6% vs -17.7%+/-2.4% (p<0.01) and -18.5%+/-3.1% vs -16.0%+/-2.9% [p<0.05], respectively). Global longitudinal strain was not significantly different from normal control subjects at the end of follow-up. In conclusion, this prospective study demonstrates (1) the existence of early longitudinal and circumferential LV systolic function abnormalities in patients with isolated paroxysmal AF but normal ejection fraction and (2) reverse remodeling of these abnormalities after AF ablation.

Heart transplantation in systemic (AL) amyloidosis: a retrospective study of eight French patients.

BACKGROUND: Immunoglobulinic (AL) amyloidosis is a complication of plasma cell dyscrasia, characterized by widespread deposition of amyloid fibrils derived from monoclonal light chains. Cardiac amyloid is the main prognostic factor, with a median survival of six months. Cardiac transplantation in AL amyloidosis is associated with high mortality, due to disease recurrence in the allograft and systemic progression. Suppression of light chain (LC) production with chemotherapy by melphalan plus dexamethasone (MD) or high dose melphalan followed by autologous stem cell transplantation (HDM/ASCT) improves survival. However, both the indications and results of chemotherapy in patients transplanted for cardiac AL amyloidosis remain unclear. AIMS: To assess the outcome of cardiac transplantation and haematological therapy in patients with cardiac AL amyloidosis. METHODS: Eight French patients, who underwent heart transplantation for cardiac AL amyloidosis between 2001 and 2006 were studied retrospectively. RESULTS: Before transplantation, six patients received MD (n=5) or HDM/ASCT (n=1). Haematological remission was obtained in three patients treated with MD. In the three remaining patients, postoperative HDM/ASCT (n=2) or allogeneic bone marrow transplantation (n=1) resulted in haematological remission in one patient. In 2 patients not treated before transplantation, post-operative treatment with MD resulted in complete hematological remission in one. After a median follow-up of 26 months from cardiac transplantation, six patients were alive and four had sustained haematological remission, as indicated by normal serum free LC levels. CONCLUSION: Appropriate haematological therapy, including MD, may result in a survival benefit in AL amyloidosis patients with advanced heart failure requiring transplantation.

Successful heart transplantation following melphalan plus dexamethasone therapy in systemic AL amyloidosis.

Recurrence in the allograft and progression in other organs increase mortality after cardiac transplantation in AL amyloidosis. Survival may be improved after suppression of monoclonal light chain (LC) production following high dose melphalan and autologous stem cell transplantation (HDM/ASCT). However, because of high treatment related mortality, this tandem approach is restricted to few patients without significant extra-cardiac involvement. A diagnosis of systemic AL amyloidosis was established in a 45-year old patient with congestive heart failure related to restrictive cardiomyopathy, nephrotic syndrome, peripheral neuropathy, postural hypotension, macroglossia, and lambda LC monoclonal gammopathy. After melphalan and dexamethasone (M-Dex) therapy, which resulted in 80% reduction of serum free lambda LC, he underwent orthotopic cardiac transplantation. Two years later, he remains in a sustained hematologic remission, with no evidence of allograft or extra-cardiac amyloid accumulation. M-Dex should be considered as an alternative therapy in AL amyloid heart transplant recipients ineligible for HDM/ASCT.

[Management of hypertension in patients with diabetes]. / Prise en charge de l'hypertension artérielle chez le patient diabétique.

Cardiovascular risk is generally high in patients with both hypertension and diabetes and should be specifically assessed for each individual. The blood pressure target is<130/80 mm Hg. Two or even three different drugs are often necessary to reach this rather difficult goal. Angiotensin-converting enzyme (ACE) inhibitors are preferred for patients with renal damage. Proteinuria should be reduced to less than 0.5 g/day. Associated risk factors should be treated with equal effectiveness. In particular, LDL cholesterol should be lowered to less than 1 g/L when additional risk factors are present. Aspirin (0.75 mg a day) should be given routinely as soon as blood pressure is controlled.