Prophylaxie de l'endocardite infectieuse en chirurgie dentaire

Chez les sujets porteurs de cardiopathies; une antibioprophylaxie bien adaptee et appliquee lors des situations ou gestes invasifs dentaires devrait diminuer le taux des greffes osleriennes qui sont grevees d'une morbi- mortalite importante. La sphere bucco-dentaire reste le site le plus pourvoyeur de bacteriemies. La prescription de l'antibioprophylaxie depend de la cardiopathie sous-jacente et du type de geste bucco-dentaire a realiser. Son efficacite a ete clairement prouvee par de nombreux auteurs qui ont demontre une reduction extremement variable mais significative du risque d'endocardite infectieuse. Le succes de cette prevention est etroitement lie a la diffusion et a l'application des recommandations sur l'antibioprophylaxie et a une meilleure collaboration Medecins- Chirurgiens dentistes

[Mobile and obstructive thrombus of the left atrium. Value and risks of transesophageal echocardiography. Report of a case and review of the literature]. / Thrombus mobile et obstructif de l'oreillette gauche. Intérêt et risques de l'échocardiographie transoesophagienne. A propos d'un cas et revue de la littérature.

Authors report the observation of a young woman of 30 years hospitalised for degeneration of a mitral biologic prosthesis. Transthoracic echocardiography visualizes a voluminous mass of the left auricle of which the character free and destitute of all parietal attachment, doesn't have can be established that by transoesophageal echocardiography that detects another thrombus also free and mobile of the left auricule, unrecognised by transthoracic way. The operative indication is carried in emergency but the patient dies suddenly some hours after this exam. From this observation and a revue of the literature, the contribution and risks possible transoesophageal echocardiography in the exploration of the mobile thrombi of the left auricle, are analysed. Account-held of the potential gravity of homodynamic and embolic complications, the emergency of the surgical indication is underlined.

[Predictive factors of atrial fibrillation in mitral stenosis. Clinical and echocardiographic study]. / Facteurs prédictifs de la fibrillation auriculaire dans le rétrécissement mitral. Etude clinique et échocardiographique.

The objective of this study was to define the predictive factors of atrial fibrillation in pure or very predominant mitral stenosis in a series of 472 consecutive patients divided into 2 groups according to the presence (group I: n = 113) or absence (group II: n = 359) of permanent atrial fibrillation. Univariate analysis showed that predictive factors for atrial fibrillation in mitral stenosis are age (40.3 +/- 9 years vs 31.4 +/- 9.5, p < 0.0001), history of commissurotomy or mitral angioplasty (13 cases vs 10, p < 0.01), functional class III or IV (36 cases vs 43, p < 0.01), history of valvular heart disease (8.4 +/- 7.3 years vs 6.4 +/- 9.2, p < 0.05), left atrial diameter (53.3 +/- 10.3 mm vs 46.5 +/- 8.5, p < 0.0001) and mitral surface area (1.1 +/- 0.4 cm2 vs 1.3 +/- 0.4, p < 0.0001). On multivariate analysis, age and left atrial dilatation were independent predictive factors of atrial fibrillation in mitral stenosis.

[Muscle bridge and myocardial ischemia. Study of 6 cases]. / Pont musculaire et ischémie myocardique. Etude de 6 cas.

The authors analyse the clinical and therapeutic aspects of myocardial bridges in a series of 6 male patients between the ages of 41 and 61 years. In every cases, the presenting signs were ischaemic order: one myocardial infarction, three cases of unstable angina and two case of stable angina. On coronary angiography, these muscle bridges involved the left anterior descending artery in all cases. The causal relationships between muscle bridges and myocardial ischaemia are discussed. Among the various factors incriminated, spasm, tachycardia and thrombosis appear to play an important role. Depending on the case, treatment modalities consist of beta-blockers, platelet antiaggregants and calcium channel blockers. Surgical treatment is reserved for patients who remain symptomatic despite medical treatment.

Theoretical model for myocardial functional characterization: application to a group of patients evaluated before and after surgical revascularization.

BACKGROUND: The functional improvements resulting from coronary revascularization (CABG) in patients with depressed ventricular function may be described by the use of a model combining global or local quantification of myocardial perfusion, viability, and contraction. An illustration of this model, with data provided by conventional radionuclide studies as they are performed routinely in many centers, is presented and the limitations of this approach for predicting the results of CABG are discussed. METHODS AND RESULTS: The model is based on three independent variables, which can be approximated in this preliminary study by parameters derived from standard stress and redistribution/reinjection thallium-201 single-photon emission computed tomography (SPECT) acquisitions with quantification of the tracer uptake defects and from a planar gated blood pool left ventricular ejection fraction (LVEF) measurement: Perfusion is assumed to correspond to 100-stress defect (in percentage), viability is 100-redistribution/reinjection defect, and contraction is 100(LVEF/70), assuming that a normal 70% LVEF corresponds to 100% contraction. In a group of 30 patients prospectively evaluated with this protocol and included in the study on the basis of a pre-CABG LVEF <40%, a significant improvement in LVEF was demonstrated (28.2% +/- 8.5% before CABG vs 35.8% +/- 7.3% after CABG), which is accompanied by a significant decrease of the stress thallium defects (34.8% +/- 13.8% vs 25.6% +/- 10.6%), whereas the average (but not the individual) redistribution/reinjection defects remain almost stable (27.7% +/- 10.9% vs 25.7% +/- 10.1%). As reported in the three-dimensional model, pre-CABG and post-CABG representative points clearly demonstrate the functional improvements for the main variables, but there is a large spectrum of responses to revascularization. It appears that the border between reversible and nonreversible thallium defects does not match the limit between ischemic myocardium (with no contraction alteration and therefore without contraction improvement potential) and hibernating myocardium, which is able to recover mechanical function and therefore is responsible for the improvement of global LVEF. CONCLUSIONS: Thallium SPECT is far from ideal for use as an independent characterization of perfusion and viability because hibernating myocardium may be present in both the fixed and reversible parts of thallium defects. Prediction of functional recovery is conditioned by an accurate identification of viable but underperfused and noncontracting myocardium. In the future, with the use of adequate study protocols that are able to measure viability without interference of perfusion and perfusion independent of viability, the proposed model may be able to characterize regional function as a cluster of representative points for each territory and to delineate areas of the theoretical volume corresponding to a potentially recoverable situation.

[Predictive indices of the persistence of left ventricular dilatation after valve replacement for chronic aortic insufficiency. Echocardiographic study]. / Indices prédictifs de la persistance de la dilatation ventriculaire gauche après remplacement valvulaire pour insuffisance aortique chronique. Etude échocardiographique.

The objective of this study was to define the echocardiographic indices predictive of persistence of left ventricular dilatation one year after valve replacement for chronic aortic incompetence. Thirty four consecutive patients (32 men and 2 women, age: 35.6 +/- 10 years) operated for post-rheumatic chronic aortic incompetence, were included in this series. All patients were investigated by echocardiography less than 15 days before and one, six and twelve months after surgery. The parameters studied consisted of measurement of ventricular diameter, shortening fraction and ejection fraction as well as aortic incompetence Doppler indices (jet-left ventriculr outflow tract diameter, jet-left ventricular outflow tract diameter/subaortic diameter ratio, half-pressure time, aortic isthmus end-diastolic velocity). Preoperative echocardiographic data and the results one year after valve replacement were compared for each patient. The left ventricle remained more dilated at one year in patients with a preoperative end-diastolic diameter > 80 mm, an end-systolic diameter > 55 mm, a shortening fraction < 25%, an ejection fraction < 50%, a jet diameter > 16 mm, a jet diameter/subaortic diameter ratio > 65% or a half-pressure time < 350 ms. In conclusion; an end-diastolic diameter > 80 mm, an end-systolic diameter > 55 mm, a shortening fraction < 25%, a jet diameter > 16 mm, a jet diaméter/subaortic diameter ratio > 65% and a half-pressure time < 350 ms appear to represent the main predictive factors of the persistence of ventricular dilatation one year after aortic valve replacement for chronic aortic incompetence.

[Predictive factors of thromboembolic complications in mitral stenosis in sinus rythm]. / Facteurs prédictifs des complications thrombo-emboliques dans le rétrécissement mitral en rythme sinusal.

The authors analyse the predisposing factors to the development of thromboembolic complications in mitral stenosis in sinus rhythm and propose preventive therapeutic measures. Eighty five consecutive patients with pure or very predominant mitral stenosis in sinus rhythm were included in this study and divided into two groups according to the presence (Group I: n = 27, age: 34.2 +/- 8.31 years) or absence (Group II: n = 58, age: 32.6 +/- 9.7 years) of thromboembolic complications. No significant difference was observed between the two groups for age, sex and functional class. Patients of group I had a more dilated left auricle (57.3 +/- 4.5 vs 48.4 +/- 4.7 mm; p < 0.001) and a smaller mitral surface area (0.8 +/- 0.15 vs 1.1 +/- 0.21 cm2, p < 0.05). The spontaneous left intra-atrial contrast phenomenon was more frequently observed in patients with thromboembolic complications (23 out of 27) than in those not presenting this complication (17 out of 58), (p < 0.001). This phenomenon was the only independent predictive factor on multivariate analysis. In conclusion, left atrial dilatation, the severity of mitral stenosis and especially the presence of spontaneous contrast are the main predictive factors of the development of thromboembolic complications in mitral stenosis in sinus rhythm. Patients presenting one or several of these factors may benefit from prophylactic anticoagulant treatment.

[Correlation between transthoracic and transesophageal echocardiography and surgery in mitral stenosis]. / Corrélation entre l'échocardiographie transthoracique et transoesophagienne et la chirurgie dans le rétrécissement mitral.

This prospective study was designed to analyse transthoracic and transesophageal echocardiographic findings in the morphological study of the mitral valve and to compare them with surgical findings. This study was based on a series of 60 consecutive patients (38 men and 22 women with a mean age of 36.3 +/- 4.2 years) undergoing open heart surgery for pure or very predominant symptomatic mitral stenosis between November 1993 and December 1994. All patients were investigated by transthoracic and transesophageal echocardiography an average of 3 days before the surgical operation. Qualitative analysis of the mitral valve was rigorously performed according to a 4-point severity score taking into account mobility, thickness and degree of valve calcification as well as the condition of the subvalvular apparatus. The global echocardiographic score corresponded to the sum of the scores for these 4 elements. Transesophageal echocardiographic data and surgical findings were identical: global score: 9.3 vs 9.5, mobility: 2.8 vs 2.9, thickness: 2.6 vs 2.5, calcifications: 1.7 vs 1.8, condition of the subvalvular apparatus: 2.2 vs 2.3. The degree of valve damage was overestimated by transthoracic echocardiography compared to surgical data: global score: 10.4 vs 9.5 (p < 0.05), mobility: 3.1 vs 2.9 (p < 0.05), thickness: 2.8 vs 2.5 (p < 0.01), calcifications: 2.1 vs 1.8 (p < 0.01), but the difference was not significant for the condition of the subvalvular apparatus: 2.4 vs 2.3. In conclusion, surgical findings in pure or very predominant mitral stenosis are more closely correlated with transesophageal echocardiographic data than with transthoracic echocardiography, which tends to overestimate the severity of anatomical lesions, particularly valvular calcification.

[Early surgery in acute endocarditis complicated by cardiac insufficiency; the Moroccan experience]. / Chirurgie précoce dans l'endocardite aiguë compliquée d'insuffisance cardiaque; l'expérience marocaine.

The aim of this review of 20 cases was to identify the surgical indications in heart failure complicating the acute phase of left heart valve endocarditis, to determine the optimal timing of surgery and to evaluate the early and medium term postoperative prognosis. Between January 1985 and May 1990, 20 patients (14 men and 6 women with an average age of 29 +/- 7 years) with native left heart valve endocarditis underwent surgery in the acute phase complicated by heart failure. The were 9 aortic regurgitations and 2 mixed mitral and tricuspid regurgitations. The haemodynamic status of the patients was poor before surgery: 15 NYHA class IV and 5 class III. The average time from the onset of heart failure to surgery was 21 days. The surgical procedure was monovalvular replacement in 14 cases, double valve replacement in 4 cases and 2 isolated mitral valvuloplasties. Two patients died in the first postoperative month of irreducible low output syndrome. One patient was reoperated early for dehiscence of a mechanical valve prosthesis. Late complications included 2 cerebrovascular accidents and one reoperation for degeneration of a bioprosthesis. There were no late fatalities. Seventeen of the 18 survivors are regularly followed up with an average of 80 months follow-up: 12 NYHA class I and 5 class II. The most useful prognostic factor was the preoperative haemodynamic status.(ABSTRACT TRUNCATED AT 250 WORDS)

[Correlation between the persistence of ST elevation and left ventricular aneurysm in the post-infarction period]. / Corrélation entre la persistance du sus-décalage du segment ST et l'anévrysme du ventricule gauche dans le post-infarctus.

The objective of this study was to verify whether the persistence of ST elevation on ECG after myocardial infarction was well correlated with the presence of left ventricular aneurysm. This study concerns 30 male patients with a mean age of 46 +/- 7.6 years, with ST elevation of more than 1 mm on ECG, at least 15 days after the presumed onset of myocardial infarction. All patients were investigated by echocardiography and cardiac catheterization. ST elevation was recorded in the ECG leads corresponding to the site of necrosis. 2D echocardiography identified 21 cases (70%) of left ventricular aneurysm and cardiac catheterization revealed 26 cases (86%). The electrical site of ST elevation was correlated with the site of the aneurysm. In conclusion, the persistence of ST elevation on the ECG more than 15 days after the onset of myocardial infarction has a good predictive value for the presence of left ventricular aneurysm, which can only be confirmed by cardiac catheterization.

[Effort phlebitis of the upper limb. Presentation of 2 cases and review of the literature]. / Phlébite d'effort du membre supérieur. Présentation de deux cas et revue de la littérature.

Effort phlebitis, which represented the principal aetiological form of deep vein thromboses of the upper limb, has become rare, while secondary forms, especially iatrogenic, are more frequent. The authors report two documented cases of effort phlebitis of the upper limb in two manual labourers aged 38 and 40 years. The aetiopathogenic and clinical features and clinical course of this disease are analysed.

[Hydatid cyst of the heart. Contribution of two-dimensional echocardiography. Apropos of 2 cases surgically treated]. / Kyste hydatique du coeur. Apport de l'échocardiographie bidimensionnelle. A propos de 2 cas opérés.

The authors report the cases of two young Moroccan patients with hydatic cysts of the heart diagnosed by echocardiography. The clinical, radiological and electrocardiographic signs were non-specific. Two-dimensional echocardiography provided a rapid anatomical diagnosis. There were no other visceral localisations of the hydatid disease. In the second case, the hydatid serology was positive and the vascular relations to the tumour were determined preoperatively by coronary angiography. Surgical ablation was performed in both cases. These two cases illustrate the diagnostic value of two-dimensional echocardiography in hydatid cyst of the heart and underline the absolute necessity of surgical ablation before complications develop.