Multimodality imaging assessment of a caseous calcification of the mitral valve annulus.

Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

[Role of intravascular ultrasound (IVUS) in determining the therapeutic strategy for the patients with intermediate coronary lesions]. / Apport de l'échographie endocoronaire (IVUS) dans la stratégie thérapeutique des lesions coronaires intermédiaires.

BACKGROUND: Coronarography presents some limits in assessing intermediate stenosis. Intravascular ultrasound provides tridimensional measurements of the artery, with more reliable data guiding revascularization decision. AIMS: to evaluate the impact of intravascular ultrasound measurements on revascularization decision of intermediate and ambiguous coronary lesions. METHODS: We prospectively analysed 40 patients' coronary arteries from March 2009 to November 2011 by both quantitative coronary angiography (QCA) then intravascular ultrasound, and compared our decision before and after intravascular ultrasound. RESULTS: in the final revascularization decision after intravascular ultrasound, medical treatment rate raised from 22% to 25%, percutaneous coronary intervention dropped from 55% to 50%, and coronary artery bypass graft slightly raised from 23% to 25%. Therapeutic decision changed after intravascular ultrasound in 47% of patients (p=0,01), which reflects an important impact of this technique in management of intermediate coronary lesions. CONCLUSION: Intravascular ultrasound provided more accurate measurements which permitted a better detection of ischemia and influenced notably our therapeutic strategies.

Cardiac events in Costello syndrome: One case and a review of the literature.

Costello syndrome is a rare syndrome associated with de novo mutations in the HRAS gene. It is mostly revealed during in the first months of life by growth retardation, facial dysmorphic features, skin and cardiac abnormalities and subsequent cognitive deficit of varying severity. We report a case of Costello syndrome in a 3-month-old infant. The initial cardiac investigations were normal except frequent premature atrial complexes. After few months, worsening arrhythmia with bursts of ventricular tachycardia were noted as well as the secondary progressive obstructive left ventricular hypertrophic cardiomyopathy (HCM). Cardiac involvement is determinant for the prognosis of Costello syndrome. It frequently consists of hypertrophic cardiomyopathy (one third of patients), with involvement of the left ventricle in half of the cases. It is often asymmetrical and associated with obstruction of the outflow recalling family hypertrophic cardiomyopathy. The natural history of HCM in Costello syndrome and its management remains poorly known because of paucity of reported cases. Progression of the HCM can be very rapid like the reported case. On the other hand, the spontaneous regression of the HCM in some patients has been reported. In addition, cardiac threatening arrhythmias may be noted. So that, cardiac assessment and monitoring with regular echocardiography and electrocardiogram follow up is mandatory.

[Limits of quantitative coronary angiography (QCA) in intermediate stenosis measuring: a correlation and concordance study with intravascular ultrasound (IVUS)]. / Les limites de l'angiographie semi quantitative (QCA) dans l'évaluation des sténoses coronaires intermédiaires: étude de correlation et de concordance avec l'échographie endocoronaire (IVUS).

BACKGROUND: Although coronarography is still the gold standard to evaluate coronary lesions, it remains a bidimensional representation of a tridimensional complex structure, which can represent a source of error in measurements. AIMS: to perform a correlation and concordance study between quantitative coronary angiography (QCA) and intravascular ultrasound measurements for intermediate and ambiguous lesions. METHODS: We analysed 40 patients' coronary arteries from March 2009 to November 2011 by both QCA and intravascular ultrasound to perform then a correlation and concordance study. RESULTS: the correlation study confirmed the limits of the angiogram in providing accurate measurements. The correlation coefficient was yet high in reference diameters (r=0,78, p<0,001) and minimal lumen diameters (r=0,58, p<0,001), but was middling for stenosis percentages (r=0,23, p=0,03). This coefficient was also high for lesions lengths (r=0,51, p=0,01). Bland &Altaman diagrams showed however wide limits of agreement, reflecting possibility of large measurements error and confirming the absence of concordance between the two techniques. CONCLUSION: Coronarography though being the most widespread mean of evaluating coronary lesions lacks to provide accurate measurements, which can influence patient's management, especially in case of intermediate lesions.

[Benefits of coronary revascularization in septuagenarian patients with acute coronary syndrome]. / Bénéfice de revascularisation coronaire chez les patients septuagénaires au décours d' un syndrome coronarien aigu.

BACKGROUND: Prognosis of acute coronary syndrome (ACS) in elderly patients is bleak. Also older people tend to receive less invasive treatment than younger patients. AIM: To analyze the impact of coronary revascularization on the mid-term outcome of septuagenarian patients admitted with ACS. METHODS: We retrospectively studied 250 patients 70 years or older hospitalised for ACS between january 2006 to september 2010. RESULTS: This population was more likely to be male with mean age 74 years and 93 % of ACS were inaugural events (60% NSTEMI, 40% STEMI). Coronary angiograms showed complex coronary lesions with a high incidence of multivessel disease, bifurcation lesions, and calcified stenosis. Seventy-six patients were treated medically and 174 underwent percutaneous or surgical revascularization. At six-month clinical follow-up, major adverse cardiac events (MACE) were significantly higher in medically treated than revascularized patients (62% Vs 31.7%, P <0.001). Patients with invasive strategy have significantly higher event free survival rate comparing to those assigned to medical management (64% Vs 49.7%, p: 0.01). CONCLUSION: Our study confirmed the superiority of invasive strategy compared to medical treatment in septuagenarian patients with acute coronary syndromes. Advanced age should not exclude patients from invasive strategy with complete revascularization.

Pistachio (Pistacia vera L.) is a new natural host of Hop stunt viroid.

Besides hop, Hop stunt viroid (HpSVd) infects many woody species including grapevine, citrus, peach, plum, apricot, almond, pomegranate, mulberry and jujube. Here, we report the first detection of HpSVd in pistachio (Pistacia vera L.). Samples corresponding to 16 pistachio cultivars were obtained from a nearby almond collection. From these samples, low molecular weight RNAs were extracted for double polyacrylamide gel electrophoresis, northern-blot analysis and reverse transcription polymerase chain reaction assays. HpSVd was detected in 4 of the 16 pistachio cultivars in the first year and in 6 in the second, being also detected in the almond collection. Examination of the nucleotide sequences of pistachio and almond isolates revealed 13 new sequence variants. Sequences from pistachio shared 92-96 % similarity with the first reported HpSVd sequence (GenBank X00009), and multiple alignment and phylogenetic analyses showed that one pistachio isolate (HpSVdPis67Jabari) clustered with the plum group, whereas all the others clustered with the hop, and the recombinants plum-citrus and plum-Hop/cit3 groups. By identifying pistachio as a new natural host, we confirm that HpSVd is an ubiquitous and genetically variable viroid that infects many different fruit trees cultivated worldwide.

[Coronary angiographic characteristics in septuagenarian patients with acute coronary syndrome]. / Caractéristiques angiographiques des septuagénaires hospitalisés pour syndromes coronariens aigus.

BACKGROUND: Although the prognosis of acute coronary syndrome (ACS) in elderly patients is bleak , elderly population is less well treated both in medical and interventional terms. aims: to analyse angiographic findings in septuagenarian patients admitted with ACS and its impact on the therapeutic strategy. METHODS: We retrospectively analysed 250 patients 70 years or older hospitalised for ACS who underwent a coronary angiography between january 2006 to September 2010. RESULTS: This population was more likely to be male with mean age 74 years and 93 % of ACS were inaugural events (60% N STEM, 40% STEMI).Coronary angiograms showed complex, diffuse coronary lesions with a high incidence of multivessel coronary artery disease , bifurcation lesions , and calcified stenosis. CONCLUSION: Angiographic findings after ACS in elderly were characterised by multivessel disease and complex lesions .Surgical or percutaneous coronary revascularizaion was possible in the majority of these patients.

Comparison of coronary calcifications detection by angiogram versus intravascular ultrasound.

BACKGROUND: The presence, extent and location of calcium in coronary artery lesions are important determinants of the success of per cutaneous coronary intervention (PCI). Although coronarography remains the gold standard for coronary disease detection, Intravascular ultrasound ( IVUS) is proposed as a superior technique for identifying patients with coronary artery calcification . AIM: To define sensibility and specificity of coronary angiography in detecting calcifications considering the IVUS as gold standard. METHODS: Target lesion calcification was assessed in 40 patients (35 men; mean age 57.4 ± 10 years) by angiography and intravascular ultrasound. RESULTS: Ultrasound detected calcium in 51 of 85 target lesion (60%),whereas angiography showed calcifications in only 16 lesion (19% p<0.001 compared with IVUS). Coronary angiography detected 8% of 0-45° arc calcium category, 7% of 45-90° calcium category, 58% of 90-180° calcium category, and 80% of more than 180° calcium category. The overall sensitivity of angiography in identifying calcium was 31% and increased with an increasing arc of lesionassociated calcium. The overall specificity of the angiographic detection of target lesion calcium was 100%. CONCLUSION: Intra coronary ultrasound analysis shows that target lesion calcification is much more widespread in coronary artery disease than what angiography reveals. The sensitivity of angiography was poor, with although a very high specificity.

Single-strand conformation polymorphism for molecular variability studies of six viroid species.

Molecular diversity within six viroid species and different molecular variants, in each species infecting fruit trees was first estimated by the single-strand conformation polymorphism (SSCP) technique and then by direct sequencing analysis. The different variants studied are to three Australian grapevine viroids(AGVd), four citrus dwarfing viroids (CDVd), eleven grapevine yellow speckle viroids type-1 (GYSVd-1), four hop stunt viroids (HSVd), seven peach latent mosaic viroids (PLMVd), and eight pear blister canker viroids (PBCVd). Polyacrylamide gel electrophoresis (PAGE) conditions were compared and optimized to improve the sensitivity of the existing SSCP parameters. The relationships among the various SSCP profiles observed and the variation in nucleotide sequences was studied. The results indicate that the variations of some parameters of electrophoresis for each species allowed higher resolution and hence detection of single nucleotide variations among clones initially clustered into the same group.

[Coronary artery bypass grafting in diabetic patients: early and mid-term outcomes]. / La chirurgie du pontage aorto coronaire chez les diabétiques : Résultats immédiats et à moyen terme.

BACKGROUND: The outcome of coronary artery bypass grafting (CABG) in diabetic patients has traditionally been worse than in nondiabetic patients. Recent studies have suggested an improvement in outcome in diabetic patients undergoing CABG. However, the direct impact of diabetes on mortality and morbidities following CABG remains unclear. AIM: To evaluate the early and mid term outcomes of diabetic patients compared to non-diabetics following CABG. METHODS: We retrospectively analyzed the data of 228 CABG patients from January 2005 to December 2010: one hundred and twenty-six diabetics and 102 non-diabetic.Diabetic patients were more likely to be female(27% Vs 12.7% P=0.009) were less smoker (55.6% Vs 80.4% P<0.0001) with higher rate of three vessel disease(67.5% Vs 42.2% P=0.005) compared to non-diabetics. RESULTS: Hospital mortality was significantly higher among diabetic patients (16% Vs 4.1% P=0.005).Length of care unit stay was more important (2.3 days Vs 2.1 days P=0.048) , but with a similar rate of sternal wound infection even after bilateral internal thoracic artery grafting. After 28 months mean follow- up, mid-term survival of diabetics was significantly decreased compared to no-diabetics (91% Vs 99% p<0.001) .However, Event-free survival was similar in the two groups (76% Vs 80% p=0.82). CONCLUSION: These results suggest that diabetes is associated with poorer early and mid-term outcomes following (CABG).

Sequence analysis of three citrus viroids infecting a single Tunisian citrus tree (Citrus, reticulata, Clementine)

We report the nucleotide sequences of three citrus viroids belonging to three different genera: Citrus exocortis viroid (CEVd), Hop stunt viroid (HSVd) and Citrus viroid-III (CVd-III) isolated from a single natural infected Citrus reticulata var. Clementine tree growing in a tree nursery in Manouba (near Tunis Capital). We describe the sequence variability of these viroids from their natural host without using an alternative passage by an indicator host or an artificial inoculation. This work confirms that naturally occurring viroid infections contain a mixture of sequence variants. These are the first sequences of citrus viroids from Africa.