[Extensive cardiac thombosis in a patient with disseminated intravascular coagulation]. / Thrombose extensive intracardiaque dans un contexte de coagulation intravasculaire disséminée.

Disseminated intravascular coagulation is a syndrome characterized by thrombin and fibrin generation which is associated with organ failure and death. Intracardiac thrombus may occur and further deteriorate prognosis. We report the case of a patient with massive intraventricular thrombus revealed by an acute ischemia of the upper left limb in a context of pulmonary adenocarcinoma complicated by a disseminated intravascular coagulation. We describe the diagnostic modalities and the fatal evolution.

[Acute myocarditis in a patient with dengue infection]. / Myocardite aiguë induite par la dengue.

Dengue is a febrile viral illness transmitted by Aedes Aegypti mosquito with growing incidence, it could be associated with cardiovascular complication mediated by inflammation and notably acute myocarditis. We report the case of a 36-year old woman admitted in cardiology department with initial diagnosis of acute coronary syndrome and ultimately diagnosed to have an acute myocarditis induced by dengue infection; we describe diagnostic modalities and clinical evolution.

[Ruptured sinus of Valsalva aneurysm presenting as an idiopathic pericardial effusion]. / Rupture colmatée d'un anévrisme de valsalva d'évolution favorable après chirurgie.

Aneurysm of the sinus of Valsalva is a rare cardiac condition, which could be either acquired or congenital. The most frequent complication is a rupture into right cavities or more rarely into left cavities or pericardium. Rupture could be either asymptomatic or poorly tolerated with hemodynamic instability, acute heart failure or sudden death. We report the case of a 24-year-old patient with no past medical history presenting with a partially ruptured sinus of Valsalva into the pericardium and in whom the initial diagnosis was idiopathic pericardial effusion; we describe diagnostic modalities and management.

A Thrombus on a Journey: A Massive Thrombus in Transit With Cerebral, Coronary, and Pulmonary Embolization.

Impending paradoxical embolism is a biatrial thrombus in transit across a patent foramen ovale. It constitutes a rare clinical condition, possibly associated with multiple embolization and high mortality. We report the exceptional case of a 71-year-old-man presenting a giant impending paradoxical thrombus, complicated with pulmonary, cerebral, and coronary embolization. The patient underwent urgent surgery and was finally discharged without complications.

Delayed Formation of a Massive Atrial Hematoma After Coronary Intervention Manifesting With an Isolated Cough: Multimodality Imaging and Outcome.

Coronary artery perforation is a relatively rare but potentially life-threatening complication of percutaneous coronary intervention because it could result in cardiac tamponade; exceptionally, distal coronary perforation could cause an acute formation of a mural hematoma, which could also prove lethal without adequate management. We report an exceptional case of a 76-year-old man in whom an important left atrial hematoma formed progressively over weeks after a planned percutaneous coronary intervention and manifested with an isolated cough. Diagnosis was made using multimodality imaging. A conservative strategy was adopted and produced a favourable outcome.

Chronic calcific constrictive pericarditis complicating Churg-Strauss syndrome: first reported case.

Churg-Strauss syndrome is a necrotizing systemic vasculitis characterized by extravascular granulomas and eosinophilic infiltrates of small vessels. Although cardiac complications are considered to be relatively common, no case of constrictive calcified pericarditis has ever been previously described in this setting. In this report, we present the case of a 46-year-old man with Churg-Strauss syndrome, in whom we were able to document the development of symptomatic calcific constrictive pericarditis during a 10-year period despite long-term corticosteroid therapy.

Percutaneous management of lower limb ischemia after the use of vascular closure devices.

BACKGROUND: Lower extremity ischemia after the use of vascular closure devices (VCDs) after transfemoral percutaneous coronary and peripheral interventions is an infrequent though relevant clinical entity. We aimed to assess immediate and midterm outcomes of a systematic endovascular approach for the treatment of VCD-related lower limb ischemia. METHODS: Between 2006 and 2008, all the patients who developed lower limb ischemia after the use of a VCD in a high volume French institution were systematically managed percutaneously and constituted the study population. Clinical characteristics, immediate, and midterm outcomes are reported. RESULTS: Of 2944 consecutive patients undergoing VCD placement after femoral access, 18 (3 men and 15 women) had VCD-related lower limb ischemia and were all managed percutaneously. Median age was 66.5 years. Devices were Angio-Seal (St Jude Medical) in 12 cases, StarClose (Abbott Vascular Devices) in 3 cases, and Perclose (Abbott Vascular Devices) in 3 cases. Limb ischemia occurred with a median delay of 2 days after device placement. Index procedures were coronary interventions in 14 cases and peripheral in 4 cases. The occlusion site was successfully crossed in all cases. Twelve patients were treated with balloon angioplasty and 6 with stent implantation. Angiographic success was obtained in all cases. After a median 32-month follow-up, only 2 patients initially treated using percutaneous transluminal angioplasty needed reintervention consisting of a balloon angioplasty in 1 case and stent implantation in the second case. At final follow-up, all the patients were asymptomatic. CONCLUSIONS: Endovascular treatment for VCD-related limb ischemia is a feasible and effective approach resulting in excellent immediate and midterm outcomes.

Spontaneous coronary artery dissection in a 35 year-old woman with systemic lupus erythematosus successfully treated by angioplasty.

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischaemia with complex pathophysiology; it has been associated with several conditions such as atherosclerosis, connective tissue disorders and the peripartum period. SCAD has exceptionally been reported (three published cases) in patients with systemic lupus erythematosus (SLE). In this work, we report the original case of a 35 year-old woman with a known history of SLE who presented with an acute coronary syndrome caused by an extensive dissection of the left anterior descending artery (LAD) and the diagonal and who was successfully treated by an intravascular ultrasound (IVUS)-guided percutaneous angioplasty.

ST elevation myocardial infarction with no structural lesions after a wasp sting.

BACKGROUND: Acute coronary syndromes after hymenoptera stings and other environmental exposures are referred to as the Kounis syndrome or allergic myocardial ischemia and infarction. CASE REPORT: We report the case of a 58-year-old man with transient inferior ST-segment elevation consistent with myocardial ischemia after a single wasp sting. Urgent cardiac catheterization revealed normal coronary arteries with a normal left ventriculogram. The evaluation and treatment of cardiac ischemia associated with an allergic reaction is discussed. CONCLUSION: ST elevation myocardial infarction after wasp envenomation is an exceptional and interesting pathology with a partially elucidated pathogenesis. The management of cardiac ischemia in this setting is uncertain.

Left ventricular systolic function deterioration during dobutamine stress echocardiography as an early manifestation of diabetic cardiomyopathy and reversal by optimized therapeutic approach.

Diabetes mellitus has been associated with changes in the structure and function of the myocardium manifesting in the early stages of the disease as subtle systolic and diastolic dysfunction; the role of dobutamine stress echocardiography (DSE) in this setting remains unclear. We sought to evaluate the prevalence of dobutamine-induced systolic dysfunction amongst diabetic patients with normal at rest left ventricular ejection fraction and no coronary artery disease and to investigate whether an optimized therapeutic approach can reverse these abnormalities. 1,363 patients with DM referred to our echocardiography laboratory for DSE between January 2008 and June 2010 were prospectively investigated. Patients with normal left ventricular ejection fraction (LVEF) at rest and significant deterioration during peak dobutamine infusion (defined as a ≥10% decrease) in the absence of coronary artery disease or vasospasm were enrolled. They received on top of their usual treatment 5 mg perindopril and had their glycemic control intensified. At 60 days, all of them were controlled for clinical status and underwent a control DSE. 18 patients were included, there were 9 males and 9 females, mean age was 66.1 ± 10.2 years. All the patients had type II DM with a mean duration of 12.7 ± 6.6 years. They all had normal at rest echocardiographic findings with no wall motion abnormalities; mean LVEF was 62 ± 6%. At peak dobutamine, LVEF significantly deteriorated in all the patients with a mean 15 ± 5% decrease compared to baseline. After therapeutic optimization, Glycated haemoglobin improved from 8.53 ± 2.05% to 6.8 ± 0.6% (δ HbA1C = 1.73%, P = 0.001), mean LVEF at peak dobutamine infusion evolved from 47.17 ± 4.2% pre-optimization to 58 ± 4.8% at control (10.83% improvement; P < 0.001). In patients with DM and normal at rest LVEF, Dobutamine infusion during DSE can induce a significant deterioration in LVEF in the absence of coronary artery disease or vasospasm. This specific condition could be largely reversed through an optimized therapy based on a tighter metabolic control and a more stringent renin-angiotensin-aldosterone system inhibition.

Infective endocarditis complicated by fatal cerebral hemorrhage revealing an unrepaired univentricular heart in a 19-year-old woman.

Univentricular heart is a complex and rare cyanotic congenital heart disease. When not operated, affected patients exceptionally reach adulthood. We report the unprecedented case of a 19 year-old young woman, admitted to the hospital for a severe deterioration of general status and ultimately diagnosed to have an infective endocarditis with multiple vegetations in a previously undiagnosed univentricular heart of left ventricular morphology, subsequently rapidly complicated by fatal cerebral hemorrhage.

EuroSCORE is a good global predictor of long-term outcomes in high-risk but not in low-risk patients after unprotected left main angioplasty.

BACKGROUND: Percutaneous coronary intervention is increasingly emerging as a valuable alternative to surgery for the treatment of patients with unprotected left main coronary artery (ULMCA) disease. In this study, we aimed to assess the ability of the EuroSCORE risk stratification model to predict long-term major adverse cardiac events after unprotected left main angioplasty according to the individual level of risk. METHODS: Two hundred forty-six consecutive patients who underwent ULMCA in a single high volume center over a 5-year period were included. Major adverse cardiac events were defined as a combined end point of cardiac death, nonfatal myocardial infarction, or target lesion revascularization. RESULTS: Areas under the receiver-operating characteristic curve of EuroSCORE in the entire cohort were 0.687 (P = 0.005; 95% CI: 0.575-0.846) and 0.589 (P = 0.038; 95% CI: 0.511-0.673) respectively for cardiac death and major adverse cardiac events (MACE). One hundred twenty-four patients had a EuroSCORE value > 6 and constituted the high surgical risk (HSR) group. Actuarial 4-year survivals free from cardiac death and free from MACE were significantly lower in this group respectively at 84% versus 93% (log rank P = 0.02) and 50% versus 74% (log rank P = 0.004). EuroSCORE was the only independent predictor of long-term cardiac mortality by the Cox analysis (HR = 3.95, P = 0.027, 95% CI: 1.16-13.39). It had a good discriminatory power for predicting both cardiac death and MACE with AUC respectively at was 0.705 (P = 0.01, 95% CI: 0.55-0.86) and 0.65 (P = 0.013, 95% CI: 0.54-0.78) in the HSR cohort but not in the lower risk (EuroSCORE ≤ 6) cohort. CONCLUSION: EuroSCORE is a good predictor not only of cardiac death but also of MACE after ULMCA angioplasty; however, the discriminatory ability of EuroSCORE appears to be limited to patients with high surgical risk as defined by EuroSCORE values > 6.

Left main coronary artery thrombosis complicating an idiopathic retroperitoneal fibrosis in a 37-year-old man with long-standing type I diabetes mellitus.

Retroperitoneal fibrosis is an uncommon collagen vascular disease of unknown etiology, characterized by the replacement of normal retroperitoneal tissue with fibrosis and/or chronic inflammation usually surrounding the abdominal aorta and the iliac arteries and extending into adjacent anatomic structures. No cases of acute coronary syndrome in the setting of retroperitoneal disorder have been published as yet. We report a 37-year-old man with a 14-year history of type I diabetes mellitus who was admitted to the endocrinology department for a routine check up and glycemic re-equilibration and who was later diagnosed to have an idiopathic retroperitoneal fibrosis. The patient presented during his hospitalisation with a non ST elevation myocardial infarction caused by an isolated thrombus located inside the left main coronary artery successfully treated with manual thrombectomy.

Unprotected left main angioplasty in nonagenarians: clinical characteristics, procedural features and outcome: a case series study.

UNLABELLED: Limited information is available on clinical characteristics and outcomes in very old patients with unprotected left main coronary artery disease (ULMCA) undergoing percutaneous coronary intervention (PCI). METHODS: From January 2004 and December 2008, 248 patients with ULMCA stenosis underwent coronary revascularization with stent implantation. Among those, 6 were older than 90 years at the time of the procedure and were included in this study. RESULTS: There were 5 males and 1 female; mean age was 91.5 years (range 91-93). All the patients presented with acute coronary syndromes. All of them had multivessel disease with a distal left main stenosis in 4 patients. All were deemed inoperable, with a mean EuroSCORE of 12.66 (range 10-20) and a predicted mortality at 34% (range15.8-86.6%). 5 patients received bare-metal stents and 1 patient a paclitaxel-eluting stent. Rotational atherectomy was required in 2 patients. Provisional side branch T-stenting with final kissing balloons was the technique used in all bifurcation lesions. Angiographic success was obtained in all patients. There were no in-hospital deaths or complications. After a 29.8-month (range 8-59) mean follow up period, a myocardial infarction caused by late stent thrombosis occurred in 1 patient and ischemia-driven target vessel revisualization was required in another; however, all patients were alive. CONCLUSION: In the very elderly patients at excessively high risk for surgery, PCI for ULMCA disease is a suitable alternative with excellent short-term results and acceptable long-term outcomes.

Short- and long-term outcomes of surgery for active infective endocarditis: a Tunisian experience.

From January 1997 to December 2006, all patients with a Duke criteria-based definite diagnosis of infective endocarditis (IE) operated on during the active phase in a Tunisian high volume tertiary-care centre were included. Among the 186 patients with IE identified during the study period, 88 (48.35%) required surgery in the active phase. Mean age was 34.9 years, 54 (61.4%) were men. The infected valve was native in 70 cases (79.5%) and prosthetic in 18 (20.5%). Streptococcus sp. were the most common causative microorganisms. The most frequent indication for operation was congestive heart failure. There were 24 in-hospital deaths (27.27% early mortality). By multivariate analysis, severe congestive heart failure (HR=13.82, 95% CI [3.38-38.15], P<0.001) and large >15 mm vegetations (HR=6.02, 95% CI [1.48-18.52], P=0.03) were predictive of in-hospital mortality. Survivors were followed-up from 3 to 120 months, mean of 28.6. Actuarial 5- and 10-year survivals free from the combined endpoint of recurrent IE, cardiovascular death and late surgery in survivors were 69+/-5% and 63+/-7%, respectively. In conclusion, despite medical progress, surgery for endocarditis in Tunisia remains challenging and yields high mortality rates. Severe heart failure is the most powerful predictor of mortality. Long-term outcome is, however, satisfactory.