[Cardiac pseudotumor revealing Behçet's disease]. / Pseudotumeur cardiaque révélant une maladie de Behçet.

INTRODUCTION: Cardiac thrombosis is a rare complication of Behçet's disease (BD), which may present as a cardiac tumor. Its discovery precedes, in half of the cases, the diagnosis of BD. The high mortality may be associated to postsurgical complications and/or an associated involvement of pulmonary arteries. CASE REPORT: We present the case of a 31 years old Caucasian French woman, with a history of venous thromboembolic disease, who had surgery after the discovery of a right ventricle tumor. That was an organised thrombus with endomyocardial fibrosis and a diagnosis of Behçet's disease was made after the surgery. The outcome was favourable under medical treatment associating corticosteroids, colchicine and antivitamin K (AVK), without relapse four years later. CONCLUSION: The discovery of an intracardiac mass in a young patient must evoke the diagnosis of cardiac thrombus and Behçet's disease, even in the absence of predisposing ethnic or geographic factor.

Thrombolytic therapy in acute ischemic stroke patients with cardiac thrombus.

The authors describe the outcome of five patients with a cardiac thrombus selected among 183 patients with stroke (2.7 %) who were given IV tissue plasminogen activator (tPA). No early systemic or cerebral embolism occurred. Two patients made a complete recovery at 3 months. Two patients had a moderate outcome. One patient had late recurrent cerebral embolism and died. These data suggest that the presence of a cardiac thrombus is not associated with a high risk of recurrent embolism in patients with stroke who are given IV tPA.

[Papillary fibroelastoma of the heart. A review of 20 cases]. / Les fibroélastomes papillaires cardiaques. Mise au point à propos de 20 cas.

After a period during which cardiac papillary fibroelastomas were considered incidental autopsy findings cerebral and coronary arteries embolism proved their aggressiveness. Echocardiography is now able to identify them and surgical resection is rapidly required. Sea anemone like macroscopic pattern is characteristic with finely villous masses, each frond being at microscopical examination formed by a central fibroelastic core surrounded by a myxomatous layer overlied by endothelial cells. Histogenesis remains elusive and we tried to clarify it by immunohistochemical analysis of 8 of the 20 cases studied (10 autopsies, 10 surgical resections). Morphological and immunohistochemical data show that endothelial cells play the most important part in abnormal formations.

Course of valvular strands in patients with stroke: cooperative study with transesophageal echocardiography.

BACKGROUND: Native valve strands might be related to the acute stage of thrombosis or might suggest a long-term valvular change. We aimed to estimate changes in the strands in patients with stroke through a serial transesophageal echocardiographic (TEE) study. METHODS AND RESULTS: A study was conducted among patients who were referred for TEE for stroke or cardiac pathology. Patients had TEE examinations with a 5-MHz multiplane TEE probe. Echocardiography was repeated 3 months later in patients with stroke. TEE was performed in 180 patients admitted to cardiology units and in 160 patients referred to neurology units. Among 34 patients with valvular strands, 30 were referred to neurology for stroke, whereas 4 patients were admitted to cardiology (18.8% versus 2.2%, difference 16.5%, 95% confidence interval 10% to 22.9%, P =.001). Strands were located on the mitral valve in 16 patients, the aortic valve in 6 patients, and both left heart valves in 8 patients. Among the 38 valves with strands, 17 (44. 7%) were morphologically normal, 4 (10.5%) were thickened, 7 (18.4%) were redundant, and 10 (26.3%) had both abnormalities. TEE showed other abnormalities in 16 (53.3%) patients, whereas 14 patients had only strands. Twenty-six (86.6%) patients had a second TEE study 3 months later. Strands were not found in 4 (15.4%) patients (95% confidence interval 4.3% to 34.9%). CONCLUSIONS: Valvular thickening or redundancy may predispose valves to strand formation. Native valve strands usually persist and thus reflect a chronic valvular change.

[Long-term outcome of mitral valve repair of dystrophic mitral regurgitation]. / Evaluation à long terme de la chirurgie réparatrice dans l'insuffisance mitrale dystrophique.

Between January 1984 and December 1994, 130 patients underwent mitral valvuloplasty for pure dystrophic mitral regurgitation. There were 94 men and 36 women with a mean age of 61 +/- 9 years: 52 patients were in atrial fibrillation; 91% of patients were in NYHA Classes III or IV. At preoperative echocardiography, the regurgitation was assessed as Grade III or IV and classified using the Carpentier classification according to type I (dilatation of the annulus) or II (mitral valve prolapse); 95% of patients had isolated prolapse of the posterior leaflet, 3% had isolated prolapse of the anterior leaflet and 2% had prolapse of the two leaflets. After valvuloplasty, a prosthetic ring was implanted in 124 patients (95%). The early mortality was 3%; 5.3% of patients had early complications. All patients underwent control transthoracic echocardiography in the first postoperative week. They were reviewed with a second transthoracic echocardiography after a mean follow-up of 5 +/- 0.3 years and a cumulative follow-up of 657 years-patients. At the immediate postoperative echocardiography, 24 minimal residual regurgitations were observed; at long-term, 20 new mitral regurgitations developed, all mild without any clinical symptoms and 98% of patients were in the NYHA Classes I or II. At 10 years, the actuarial survival was 73 +/- 16%; absence of thromboembolic complications 95 +/- 3%, absence of reoperation 95 +/- 5%. This study confirms the efficacy of mitral valvuloplasty and the postoperative stability of repaired valvular lesions. These results suggest that the operative indications should be considered at an earlier stage.

[Papillary fibroelastoma of the heart (giant Lambl excrescence). Clinical-anatomical study on 10 surgically treated patients]. / Fibroélastomes papillaires cardiaques (excroissances de Lambl géantes). Etude anatomo-clinique de 10 cas opérés.

OBJECTIVES: The growing number of reports of surgery for papillary fibroelastomas of the heart led us to evaluate the diagnostic potential of ultrasonography in patients with cerebral or coronary signs and to assess the efficacy of anticoagulant therapy in preventing recurrent cerebral ischemia and disease progression after resection. PATIENTS AND METHODS: Ten cases of echographically diagnosed fibroelastoma of the heart treated by surgery were analyzed together with cases reported in the literature. RESULTS: Transesophageal echography has been shown to be the superior method. Surgical resection has given good results and the postoperative course is always excellent. Recurrent embolism occurred in two of our cases despite well-conducted anticoagulation. DISCUSSION: Surgical resection should be performed as early as possible because anticoagulation does not appear to sufficiently protect against embolic events, particularly cerebral events.

[Hydatid cyst of the heart]. / Kyste hydatique du coeur.

BACKGROUND: We report an unusual localization of a hydatid cyst: the septum interventriculare. CASE REPORT: A 60-year-old algerian man with hypertension was treated for cardiac insufficiency with hypereosinophilia. Cardiac echography showed a round tumor in the septum interventriculare. Serologic tests for hydatidosis were positive. Computed tomography and magnetic resonance imaging were consistent with the diagnostic of hydatid cyst. Surgical treatment was rejected because of severe underlying hypertensive cardiopathy. DISCUSSION: Cardiac hydatidosis is uncommon, but may be revealed by cyst rupture. Treatment requires surgery and associated medical management with albendazole requires further evaluation.

Giant lambl excrescences. An unusual source of cerebral embolism.

BACKGROUND: A possible association of giant Lambl excrescences (LEs) with stroke has been suggested. However, the treatment of giant LEs is controversial because minimal data are available. OBJECTIVE: To clarify the management of giant LEs through a clinicopathologic study. CASE SERIES: Three young patients (2 women and 1 man) who experienced ischemic stroke were studied. Results of general examinations were normal, as were chest x-ray films, electrocardiograms, ultrasonograms of the neck, and cerebral angiograms. Extensive serological and blood testing failed to show any coagulopathies or systemic disorders that favored a stroke in these patients. Transesophageal echocardiography showed a mitral valve lesion (width, > 1 mm). Two patients (cases 1 and 3) were discharged on a regimen of anticoagulant therapy and sequential transesophageal echocardiographic monitoring was planned, whereas 1 patient (case 2) was promptly scheduled for surgery. A second stroke occurred in patients 1 and 3 at 3 and 6 months, respectively, thus leading to surgery in these 2 patients. Findings from histopathologic studies were consistent with the diagnosis of giant LEs. The patients' outcomes were uneventful after surgery, and none had a recurrence of a stroke. CONCLUSIONS: A relationship between giant LEs and stroke may be suggested. In patients who have transesophageal echocardiographic findings that are consistent with this diagnosis and recurrent stroke despite antithrombotic therapy and without an alternative explanation for the ischemic symptoms, surgery should be considered in view of these findings.

[Fibrous aortic valve tumor (Lambl's excrescence) trapped in the right coronary artery. Apropos of a case]. / Tumeur fibreuse valvulaire aortique (excroissance de Lambl) enclavée dans la coronaire droite. A propos d'un cas.

Lambl's excrescences are filliform aortic or mitral valve tumours. They do not usually cause any clinical problems and are autopsy findings. The authors report a case of a 64 year old female with an invalidating angina in whom echo and angiographic investigations suggested obstruction of the right coronary ostium by a valvular tumour. This was confirmed at surgery and tumorectomy was followed by regression of the anginal syndrome.

[Diagnostic value of echocardiography under dobutamine in everyday practice]. / Intérêt diagnostique de l'échocardiographie sous dobutamine en pratique quotidienne.

In order to evaluate the place of dobutamine echocardiography in everyday practice, this test and a stress ECG were performed in 34 patients referred for diagnostic or assessment coronary angiography. Dobutamine, administered in 3-minute stages from 5 to 30 micrograms/kg/min, was well tolerated. The anti-ischaemic treatment was continued in 26 patients before dobutamine echocardiography and in 15 patients before the stress ECG. The electrocardiographic, echocardiographic and angiographic documents were each analysed by 2 independent observers. Dobutamine echocardiography was considered to be positive in the presence of the development of a new abnormality of segmental kinetics or when abnormality of segmental kinetics was identified outside of the territory of infarction. With reference to coronary angiography, the sensitivity of stress ECG and dobutamine echocardiography was 46% and 42%, respectively, and the specificity was 75% and 88%, respectively; the sensitivity of each test was low, probably because of fake tests. The combination of the two tests improved the sensitivity (69%) without altering the specificity (75%). Dobutamine echocardiography could usefully complete a negative stress ICG whenever a false-negative result is suspected to avoir wrongly reassuring some patients and to allow appropriate management.

Potential cardioembolic sources of stroke in patients less than 60 years of age.

Minor potential cardioembolic sources of stroke such as atrial septal aneurysm or patent foramen ovale are important risk factors for cryptogenic stroke. We aimed to determine the prevalence of these abnormalities through an exhaustive aetiological work-up. One hundred and eighteen stroke patients under 60 years of age, who had no evidence of a significant cardiac source of embolism, were classified into four groups following transoesophageal echocardiography and assessment of cervical arteries. Group A comprised 30 patients (25.4%) who had an arteriopathy, probably related to stroke without any cardiac abnormality; group B, had only a potential cardiac source; group C, nine (7.6%) had an obvious arterial source of stroke and incidental cardiac abnormalities; group D, 30 (25.4%) had neither cardiac or arterial source. Data were analysed with the Chi-square test to compare risk factors between groups, and variance analysis was used to compare age between groups. Significance was assessed as P < 0.05. Fisher's exact test was used to test the association between arterial septal aneurysm and patient foramen ovale. In groups B and D atrial septal aneurysm represented 56.8% of the cardiac abnormalities and was diagnosed in 35.4% of the 79 patients who had an unexplained stroke, and a patent foramen ovale was found in 34.1% of the patients. According to Fisher's exact test, atrial septal aneurysm was significantly associated with patent foramen ovale (P < < 0.001). On this basis, one fourth of the patients might be said to have had a truly cryptogenic stroke as the aetiological work-up failed to demonstrate any source of stroke. Comparison between groups showed that in 23% of the patients in whom an arterial source was detected, there was also a potential cardioembolic source (group C), vs 62% in patients who had no arterial source (groups B and D) (P = 0.0007). Our study confirmed the strong association between atrial septal aneurysm, patent foramen ovale and stroke. Although there was a lower incidence of cardiac risk factors for stroke in patients who had cervical artery disease, we suggest that all patients who have a stroke without evidence of a major cardiac source should undergo transoesophageal echocardiography, in order to ensure a better prevention.

Transesophageal echocardiography in patients less than 60 years of age without obvious cardiac source of embolism.

Minor potential cardioembolic sources of stroke such as atrial septal aneurysms (ASA) or patent foramen ovale (PFO) are important risk factors for cryptogenic stroke. We aim to determine the prevalence of these abnormalities through an exhaustive etiological workup including transesophageal echocardiography and cervical arteries assessment in stroke patients younger than 60 years of age who had no evidence of a significant source of embolism. We classified 118 stroke patients into four groups according to transesophageal echocardiography (TEE) and cervical arteries assessment findings. Group A, consisted of 30 (25.4%) patients who had an arteriopathy likely related to stroke without any cardiac abnormality; Group B, 49 (41%) patients who had only a potential cardiac source; Group C, 9 (7.6%) patients who had an obvious arterial source of stroke and incidental cardiac abnormalities, and Group D, 30 (25.4%) patients who had neither cardiac nor arterial source. Data were analysed with X2 test for the comparison of risk factors between groups. Variance analysis was used to compare age between groups. Significance was assessed as p < 0.05. ASA represented 56.8% of the cardiac abnormalities and was diagnosed in 35.4% of the 79 patients who had an unexplained stroke (B and D). A PFO was found in 34.1% of the patients who had a cryptogenic stroke (B and D). According to Fisher's exact test, ASA was significantly associated to PFO (p << 0.001). According to this selection one fourth of the patients might have a truly cryptogenic stroke as the etiological workup failed to demonstrate any source of stroke. Comparison between groups showed that the patients in whom an arterial source was detected also had a potential cardioembolic source in 23% of the cases (C), versus 62% in patients who had no arterial source (B and D) (p = 0.0007). Our study confirmed the strong association between ASA, PFO and stroke. Although there was a lower incidence of minor potential cardioembolic sources in patients who had a cervical artery disease, we suggest a systematic TEE screening in all patients with stroke without major cardiac source, in order to ensure a better prevention.

[Lambl's excrescence: an uncommon cause of cerebral embolism]. / Excroissance de Lambl: une cause inhabituelle d'embolie cérébrale.

A 31 year old right handed woman presented with acute onset of aphasia which cleared over two days. CT-scan showed a left middle cerebral artery infarct within Wernicke area. Initial transesophageal two-dimensional echocardiography disclosed a mitral valve lesion suggesting a thrombus. She was discharged on oral anticoagulant treatment. A second stroke occurred ten months later involving left lenticulo-striate arteries area. Echocardiography remain unchanged. Subsequently, giant Lambl's excrescences of mitral valve was confirmed by operation and pathologic examination. The majority of patients with Lambl's excrescences are asymptomatic. However surface thrombus is common with this tumors which reposant a potential us for cerebral embolization. These tumors should be operated since complete excision is the only definitive means of eliminating the source of recurrent embolization.

[Radionuclide ejection fraction at rest and in exercise in chronic aortic insufficiency. Pre- and postoperative study in asymptomatic or paucisymptomatic patients]. / Fraction d'éjection isotopique du ventricle gauche au repos et à l'effort dans l'insuffisance aortique chronique. Etude pré- et postopératoire chez les patients a- ou paucisymptomatiques.

Twenty patients (17 men and 3 women: average age 50 +/- 14 years) with asymptomatic or paucisymptomatic aortic regurgitation were studied to compare the values of radionuclide left ventricular ejection fraction (EF) at rest and on exercise before (1) and 6 +/- 1 months (2) and 5.7 +/- 1.1 years (3) after surgery. The resting EF was similar at all three examinations: 53 +/- 8 (1); 57 +/- 8 (2); 55 +/- 16 (3). However, it increased significantly on exercise from 40 +/- 10 (1) to 54 +/- 12 (2) (p < 0.001) and to 52 +/- 20 (3) (p = 0.036 versus 1). In the 7 patients with resting EF greater than 55 before surgery, there was no postoperative improvement: 61 +/- 6 (1); 61 +/- 5 (2); 65 +/- 9 (3). However, the exercise EF increased from 44 +/- 13 (1) to 55 +/- 17 (2) and 69 +/- 11 (3) (p = 0.004 vs 1). In 13 patients with resting EF < 55%, the value increased in the early postoperative phase but not later: resting: 49 +/- 5 (1); 55 +/- 8 (2) (p = 0.04); 49 +/- 17 (3) (NS vs 1); effort: 38 +/- 7 (1); 54 +/- 10 (2) (p < 0.001); 40 +/- 16 (3) (NS vs 1). Left ventricular systolic function only returns to normal and exercise after surgery in patients with resting preoperative EF > or = 55%, but nothing indicates that this normalisation is an absolute condition for a successful surgical result in aortic insufficiency in terms of survival and quality of life.

[Systematic transesophageal echocardiography during the postoperative first 24 hours after mitral valve replacement]. / Echocardiographie transoesophagienne systématique dans les 24 premières heures postopératoires après remplacement valvulaire mitral.

Systematic transoesophageal echocardiography after the 10th day of mitral valve replacement with a mechanical prosthesis has enable diagnosis of several abnormal conditions: thrombi, strands and paravalvular leaks. The aim of this prospective study was to determine the prevalence of these conditions by biplane transoesophageal echocardiography in the first 24 postoperative hours. Transthoracic and transoesophageal echocardiography was performed on average 12 +/- 3 hours after coming out of the surgical block in 77 consecutive patients who underwent mitral valve replacement with a mechanical prosthesis. Nine patients (11.7%) had appearances of thrombi or strands in the left atrium or auricle. These small thrombi (1 to 1.5 cm2) were not obstructive. No embolic events were observed in the first month of these patients. Spontaneous contrast was seen in the left atrium of 31 patients (40%). The factors associated with the presence of thrombus or strands were advanced age (p = 0.02), presence of spontaneous contrast (p = 0.02) and more dilated left atrium (p = NS) Paraprosthetic leaks were seen in 11 cases (14.3%). In 10 cases, the regurgitant jets were narrow at their origin with little extension into the left atrium. Only one patient had severe regurgitation associated with raised transprosthetic pressure gradients. Cases with paravalvular leaks had a lower incidence of spontaneous contrast (3.2% vs 21.7%) and no thrombosis. Transoesophageal echocardiography demonstrated spontaneous contrast, thrombi and strands in the initial hours following implantation of a mechanical mitral valve prosthesis. The prevalence of these appearances, comparable to that of the results reported with later investigations, underlines the importance of effective anticoagulation from the fist postoperative hours.

Assessment of left ventricular stiffness and compliance.

Invasive and non-invasive methods exist to assess left ventricular compliance (LVC). This work has two parts, one experimental and one clinical. We estimated left chamber stiffness in dogs by using volume data from radionuclide ventriculography (RNV) and left ventricular pressure data, synchronized with a gating system to the intraventricular dp/dt max to obtain volume and pressure data from a mean cardiac cycle. In five dogs after acute experimental ischaemia, the modulus chamber stiffness Kp rose from 30.2 +/- 4.4 to 55.4 +/- 5.9 (P < 0.01). In 10 dogs with experimental infarction after intra-aortic balloon pumping, Kp decreased from 33.7 +/- 5.0 to 15.5 +/- 3.9 (P < 0.01) and in five dogs with experimental infarction, after intravenous infusion of sodium nitroprusside, Kp decreased from 41.4 +/- 5.5 to 22.2 +/- 2.8 (P < 0.01). In eight normal volunteers and in 20 postmyocardial infarction patients, we estimated a parameter reflecting the LVC by using volume data with blood flow velocity at the mitral valve annulus. Assuming that the mitral flow-velocity variation reflects LV pressure changes, the formula LVC = (dv/dt)/(dp-dt) becomes (dv/dt)/(df/dt) = dv/df. Values obtained in normals were 0.841 +/- 0.295 m-1s and after myocardial infarction 0.331 +/- 0.10 m-1s. Both methods allow clear separation in groups of animals or patients according to the expected changes in LVC or stiffness.

Postoperative and long-term prognosis of myotomy-myomectomy for obstructive hypertrophic cardiomyopathy: influence of associated mitral valve replacement.

Several surgical techniques have been proposed for obstructive hypertrophic cardiomyopathy (OHCM): myotomy, mitral valve replacement (MVR), or myotomy-myomectomy (MM). We reviewed our series of 47 patients who had undergone surgery in order to determine their prognosis and to know whether MVR+MM was better than MM only. Left intraventricular gradient decreased from 86 +/- 34 mmHg to 15 +/- 20 mmHg (P < 0.0001). Postoperatively, three patients died from low cardiac output (6.4%); five died later. Annual mortality (including postoperative deaths) was 3.0%. Follow-up was 5.7 +/- 0.7 years. Survival was 87 +/- 11% at 12 years. After operation, 91% had NYHA class I or II dyspnoea (before surgery this had been 28%); chest pain was CCS class I in 88% (vs 47%); 12% had had syncope since operation (vs 53%). The gradient decrease was larger in the MM+MVR group (P < 0.05). Survival and functional improvement were similar in the two groups. Mitral regurgitation decreased from 2.7 to 0 in the MM+MVR group (P < 0.0001), whereas it decreased from 1.5 to 1.2 in the MM group (ns). MM appears to be the procedure of choice. When mitral regurgitation is important or when an intrinsic disease of the mitral valve exists, the addition of MVR should be considered.