Severe Pulmonary Hypertension Secondary to Concomitant Mitral Stenosis with Veno-occlusive Disease in the Context of Systemic Sclerosis: Importance of Careful and Comprehensive Assessment

Pulmonary Arterial Hypertension (PAH) is a clinical syndrome consisting of physiologic/ hemodynamic criteria that are a consequence of several etiologies. Confirmation of pulmonary hypertension is based on right heart catheterization. Pulmonary hypertension is a devastating condition that can lead to considerable morbidity and premature mortality. In the last few decades, significant advancement in the pharmacotherapy of pulmonary hypertension has resulted from better understanding of the complex pathogenesis and pathophysiology of this dreaded disease. Despite these accomplishments, pharmacotherapy of pulmonary hypertension is still far from perfect, and the mortality in this modern treatment era is still unacceptably high. We report a complex clinical presentation characterized by severe pulmonary hypertension secondary to concomitant mitral stenosis with veno-occlusive disease in the context of systemic sclerosis. Our case highlights the importance of a systematic and comprehensive diagnostic approach to avoid missing an underlying pathology.

The Bacterial Profile of Aortic Infectious Endocards: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective endocarditis is defined as infection of a native or prosthetic heart valve, endocardial surface, or cardiac device. The causes and epidemiology, as well as the microbiology of the disease have evolved over the last few decades with the doubling of the average age of patients and an increased prevalence in patients with indwelling cardiac devices. Patients and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at ERRAZI Hospital-Mohammed VI University Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form. Results: Over the study period, 46 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. Endocarditis on aortic prosthesis was found in 15%. The valves were rheumatic in 85%. The presumed portal of entry was cutaneous in 45%, oral and ENT in 33%, urinary in 15%, and digestive in 7%. In our series, 21 out of 26 patients presented a biological inflammatory syndrome. At least one or more blood cultures were positive in 38% of cases. Coagulase-negative Staphylococcus was the most common germ in aortic infective endocarditis, found in 40% of positive blood cultures. All the patients in our series had received a combination of broad-spectrum intravenous antibiotic therapy, initially probabilistic, taking into consideration the portal of entry. Adapted after antibiogram results. The evolution during the hospitalization, was marked by an improvement of the clinical state in only 12%, a perioperative death in 38%, and a worsening of the clinical state in 50%, with an average duration of hospitalization of 14 days. In our series, 60% of the patients with positive blood cultures died, whereas there was 75% survival in the group with negative blood cultures. Conclusion: Infective endocarditis is a serious disease because of its high morbidity and mortality. Despite improvements in diagnostic testing, antimicrobial therapy, and surgical intervention, changes in the epidemiology of IE, including the increase in healthcare-associated infections and the virulence of staphylococcus aureus as the causative organism, increase the risk of complications and death in the acute phase of IE. Action must be taken to prevent infective endocarditis, especially in this rheumatically endemic area.

Echocardiographic Aspect of Infectious Aortic Endocarditis: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective Endocarditis (IE) is a serious disease whose prognosis depends on early management. Aortic localization is characterized by its progression to myocardial failure and the high number of complications motivating early recourse to surgery. The diagnosis of AR is based on microbiological and imaging studies. Echocardiography is the recommended imaging modality to make the diagnosis, assess the impact and guide surgery. Materials and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at the ERRAZI-CHU Mohammed VI Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form. Results: During the study period, 26 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. A known history of valvular disease was found in 57% of the cases. Among the native valvular diseases, rheumatic origin was found in 85%. The most common valvular lesions were represented by vegetations (88%), which were mobile in 56%, measuring between 10 and 20 mm in half of the cases, their most predominant localization was on the ventricular side with a tilt.IE on severe IAo was found in 90% of cases. The most common associated valvulopathies were MI (53%), RAo (38%) and MR (34%), whose severity was variable. The association of aortic disease with mitral disease was the most frequent association. Echocardiographic complications were presented by fistulas, perforations and peri-aortic abscesses (2 cases each) which were correlated with severe AI. Regarding the impact of the aortic AR on the LV, we noted a marked dilatation in 42% of cases with a preserved ejection fraction in 74%. A quarter of our patients had undergone transesophageal echocardiography in addition to transthoracic echocardiography, with an average time between admission and completion of 3 days. The indication of its realization was posed in front of the doubt of the visualization of an image of vegetations or suspicion of complications not visualized with the TTE. Valvular lesions found on TEE were essentially vegetations in 45% of cases, prolapses in 22% of cases, as well as abscesses, para-prosthetic leaks and prosthesis deinsertion found in 11% of cases. Conclusion: Aortic AR remains a frequent pathology in our context. Aortic insufficiency is the most predisposing valvulopathy and the most common sonographic appearance is vegetations. The results of our study have shown that complications of AE occur preferentially in patients with severe aortic insufficiency.

Double Outlet Right Ventricle Infective Endocarditis: A Rare Combination and a Therapeutic Challenge

Infective endocarditis involving the right side of the heart occurs rarely and often involves the tricuspid valve. The isolated pulmonary valve infective endocarditis (IPVIE) is a less common condition that occurs in specific population. The double outlet right ventricle (DORV) is an unusual congenital heart disease. The association of DORV and IPVIE darkens the prognosis. We report two cases of the association of DORV and IPVIE. The transthoracic echocardiography (TTE) is the base to the diagnosis. Right sided infective endocarditis in the lack of a guided strategy remains a therapeutic challenge.

Left Ventricular Non-Compaction Cardiomyopathy: Case Report and Review of Literature

Non-compaction cardiomyopathy (NCC) is characterized by trabeculations in either one or both ventricles. Clinical presentation is highly variable: dyspnea, palpitation, thromboembolic events, arrhythmia, or sudden cardiac death. There are currently no universally-accepted criteria for classifying and diagnosing left ventricular non-compaction (LVNC) cardiomyopathy. Transthoracic echocardiography (TTE) is the diagnostic exam of choice. The diagnosis is often missed or delayed because of a lack of knowledge about this uncommon disease. Progression of LVNC is highly variable and prognosis is very difficult to predict. We report a case of a 50-year-old female patient with a history of total thyroidectomy under hormonal supplementation who consults for dyspnea and paroxysmal palpitations revealing an isolated LVNC. This case emphasizes the importance of imaging techniques, which are, TTE and cardiac magnetic resonance imaging (MRI) in early diagnosis, management, and follow-up.

Electrical, Echocardiographic and Coronary Artery Characteristics of Right Ventricular Infarction: Experience of the Cardiology Department of the CHU Mohammed VI Marrakech

Introduction: Coronary heart disease is the main cause of morbidity and mortality worldwide. Right ventricular (RV) infarction is often difficult to diagnose and has a poor prognosis due to rhythmic and hemodynamic complications. Objective: The study of electrical, ultrasonographic, and coronarographic features of the VD Infarction. Materials and Methods: Retrospective study of patients hospitalized in the Cardiology Department of the Mohammed VI University Hospital in Marrakech over a period of 24 months for MDI extended to the RV. Results: 120 patients were hospitalized during this period for MI with extension to the VD. Atypical clinical presentation was noted in 10% of cases. Clinical examination on admission revealed signs of right heart failure in 18% of cases, including 6% complicated by cardiogenic shock. Thrombolysis was performed in 10% of the patients, 67% of them successfully. The ECG found an isolated extension to the V3R leads in 76% of the cases and in association with a V4R overshoot in 45% of the cases, conduction disorders were noted in 28% of the cases, presented essentially by first degree auriculoventricular block. Echocardiography showed impaired LV function in 82% of cases, and longitudinal systolic dysfunction of the LV in 65%. Coronary angiography was performed in 91% of the cases, half of which underwent coronary angioplasty. The combination of both CD and IVA damage was found in 40% of the cases, and damage to the middle DC was the most common in almost half of the cases. The most frequent complications were rhythmic and conductive disorders in 38% of cases, and the evolution was fatal in 8% of cases. Conclusion: Involvement of the RV during MI is characterized by a very critical initial phase, once overcome, the overall prognosis becomes favorable in the long term.

Is there an Electro-Angiographic Correlation in RD Infarction?

Introduction: Coronary angiography is the examination of choice in the evaluation of coronary anatomy during acute myocardial infarction, particularly of the right ventricle (RV), whose diagnosis remains difficult. The electrocardiogram reflects the pathophysiology of myocardial ischemia, thus allowing prediction of the culprit lesion. Objective: To investigate the correlation between electrical and coronary data and to judge the reproducibility of the electrocardiogram in identifying the culprit lesion in RV infarction. Materials and Methods: Retrospective study of patients hospitalized in the Cardiology Department of the Mohammed VI University Hospital in Marrakech over a period of 24 months for MDI extended to the RV. Results: During the study period, 120 patients were hospitalized for MI with RV extension. Inferior MI represented 70% of all cases of infarction extended to the RV. It is represented electrically by isolated ST-segment elevation in V3R found in 76%, as well as in association with an elevation in V4R in 45% of cases. Conduction disorders were noted in 38% of cases, presented essentially by first degree atrioventricular block, without any electrical specificity. Coronary angiography was performed in 91% of patients, half of whom underwent coronary angioplasty. A bi-truncular involvement (RC + VIA) was found in 40% of cases, the middle DC is the culprit lesion in almost half of the cases of VD infarction. The presence of an ST elevation in the isolated V3R shunt is a specific criterion of right middle coronary involvement, found in 48% of patients. Conclusion: The ECG remains an essential tool in the early prediction of the artery responsible for the infarction. Because of its complementary nature, the combination of ECG and coronary angiography is essential for a better evaluation of acute myocardial infarction.

Infective Endocarditis: Experience of the Cardiology Department of the Mohammed VI University Hospital

Introduction: Infective endocarditis (IE) is a rare but potentially serious disease. It causes a high mortality and a high level of morbidity and complications. Its epidemiological, clinical and microbiological characteristics have changed in recent years. The Aim of our Work: Is to study the epidemiological, clinical, bacteriological, ultrasonographic, therapeutic and evolutionary data of IE between January 2017 and October 2022 in the Mohammed VI University Hospital and to compare them to the global profile. Materials and Methods: Retrospective study including 110 patients hospitalized for a definite IE, according to the modified DUKE criteria, in the cardiology department of the Mohammed VI University Hospital over a period of 5 years and 10 months from January 2017 to October 2022. Results: The average age of our patients was 43 years with a male predominance. The bacterial graft was on native valve in 80% with predominance of rheumatic origin (69%), on cardiac prosthesis in 10% of patients, on healthy heart (4%) and congenital heart disease (6%). The most frequent portal of entry was dental (30%). Blood cultures were positive only in 33% of patients, isolating a staphylococcus (16%), a streptococcus (14%) and a GNB (3%). Transthoracic echocardiography (TTE) showed vegetation in 108 cases, valve perforation in 7 cases, cord rupture in 1 patient and perivalvular abscess in 10 cases. Seventy-seven percent of patients had surgical treatment with a mean delay of 29 days. The overall mortality was 24% with heart failure (p<0.001), renal failure (p=0.004) and neurological complications (p=0.002) as predictive factors of mortality. Conclusion: Infective endocarditis remains a real health problem with a consequent mortality and morbidity. The population is often young, revealing the IE by complications; its prevention is the best way to improve its prognosis.

Dilated Cardiomyopathy with Biventricular Thrombi: A Severe Manifestation of Behcet Disease

Behcet’s disease is a systemic vasculitis of the vessels for all calibers, touching arterial and venous territories. The causes of disease are unknow. BD reaches young age subjects from 10 to 45 years and affects both men and women. BD is ubiquitous but more frequent in patients from Mediterranean basin, the middle East and Asia. The diagnosis of BD is essentially clinical. The diagnostic criteria make it possible to carry the diagnosis with good sensitivity and specifity. BD evolves by recurrent inflammatory attack. BD can affect all of the organs; cardiacs manifestations are dominated by intracardiac thrombosis, the damage of three tunics, coronaryarteritis with or without myocardial infarction, coronaries aneurysms and endomyocardial fibrosis. The vascular manifestations are dominated by arterial or venous thrombosis. The presence of dilated cardiomyopathy with reduced left ventricular ejection fraction is rare. It can be explained by ischemic or inflammatory origin by cytokines. We report a case of young woman aged of 33 years to the history of 3 episodes of bipolar aphtae which presented dilated cardiomyopathy with reduced left ventricular function, biventricular thrombosis, bilateral distal pulmonary embolism with pulmonary infarction.

Evaluation of Th17 associated antigen in Old World Cutaneous Leishmaniasis: A comparative study in acute versus chronic human cutaneous Leishmaniasis using immunohistochemistry

@#There are little information about Th17 cells and cutaneous Leishmaniasis (CL), due to an important effect of Th17 cells on immune response, it is worth to explore the role of Th17 on CL. The purpose of this study was to assess Th17 population in patients with acute vs. chronic CL lesions in comparison with skin samples collected from healthy volunteers in an endemic region of Old World CL. A total of 49 patients with clinical manifestations of chronic (n=16) and acute (n=33) CL lesions were recruited. The clinical diagnosis of CL was confirmed by direct smear or PCR. Biopsy specimens from prelesional skin of non-infectious lesions of 30 healthy individuals were used as control. Tissue sections of 3μm thickness were prepared and used for immunohistochemistry (IHC) analysis with primary antibody specific for Th17 associated antigen (CD161). For IHC, Envision+ (DakoCytomation) system was used and developed by using diaminobenzidine (DakoCytomation). The mean age of 33 patients with acute CL and the mean age of 16 patients with chronic CL were accordingly 45.24±16.43 and 33.56±15.87. In acute and chronic CL the mean (±standard deviation) and median (±interquartile range) were accordingly 2.92±2.21, 2.56±2.9 and 2.1±1.99, 1.54±2.81. In healthy controls the mean (±standard deviation) and median (±interquartile range) were 0.72±0.41 and 0.61±0.58 respectively. With pairwise comparison of acute, chronic and control groups, there were significant difference between acute and control (P value < 0.001), chronic and control (P value = 0.043). The results showed that there was an increasing cellular response of Th17 in both acute and chronic CL patients. Th17 was significantly higher in patients with acute and chronic CL lesions in comparison with healthy control group. However, there was no significant difference between acute and chronic infection concerning to Th17 cells.