The onset of left ventricular diastolic dysfunction in SHR rats is not related to hypertrophy or hypertension.

Left ventricular (LV) diastolic dysfunction, particularly relaxation abnormalities, are known to be associated with the development of LV hypertrophy (LVH). Preliminary human and animal studies suggested that early LV diastolic dysfunction may be revealed independently of LVH. However, whether LV diastolic dysfunction is compromised before the onset of hypertension and LVH remains unknown. We therefore evaluated LV diastolic function in spontaneously hypertensive rats (SHR) at different ages and tested whether LV diastolic dysfunction is associated with abnormal intracellular calcium homeostasis. LV systolic and diastolic functions were evaluated by invasive and echocardiographic methods in 3-week-old (without hypertension) and 5-week-old (with hypertension) SHR and Wistar-Kyoto control rats. Basal intracytoplasmic calcium and sarcoplasmic reticulum (SR) Ca(2+) contents were measured in cardiomyocytes using fura-2 AM. Sarco(endo)plasmic Ca(2+)-ATPase isoform 2a (SERCA 2a) and phospholamban (PLB) expressions were quantified by Western blot and quantitative RT-PCR techniques. LV relaxation dysfunction was observed in 3-week-old SHR rats before onset of hypertension and LVH. An increase in basal intracytoplasmic Ca(2+) and a decrease in SR Ca(2+) release were demonstrated in SHR. Decreased expression of SERCA 2a and Ser16 PLB (p16-PLB) protein levels was also observed in SHR rats, whereas mRNA expression was not decreased. For the first time, we have shown that LV myocardial dysfunction precedes hypertension in 3-week-old SHR rats. This LV myocardial dysfunction was associated with high diastolic [Ca(2+)](i) possibly due to decreased SERCA 2a and p16-PLB protein levels. Diastolic dysfunction may be a potential predictive marker of arterial hypertension in genetic hypertension syndromes.

Clinical characteristics and outcome of infective endocarditis in adults with bicuspid aortic valves: a multicentre observational study.

OBJECTIVE: To analyse characteristics and outcomes of infective endocarditis (IE) on bicuspid aortic valves (BAV) and to compare the risk of death according to the presence or absence of BAV. DESIGN: 5-year observational study. SETTING: Population of 856 patients with definite IE according to the Duke criteria from two tertiary centres (Amiens and Marseille, France). PATIENTS: 310 consecutive patients with definite native aortic valve IE enrolled between 1991 and 2007. INTERVENTIONS: Patients underwent transthoracic and transoesophageal echocardiography during hospitalisation. Surgery was performed on a case-by-case basis according to conventional guidelines. MAIN OUTCOME MEASURES: In-hospital mortality and 5-year overall mortality. RESULTS: Patients with BAV IE (n=50, 16%) were younger, had fewer comorbidities and a higher frequency of aortic perivalvular abscess (50%). Presence of BAV (OR 3.79 (1.97-7.28); p<0.001) was independently predictive of abscess formation. Early surgery was performed in 36 BAV patients (72%) with a peri-operative mortality of 8.3%, comparable to that of patients with tricuspid aortic valve IE (p=0.89). BAV was not independently predictive of in-hospital mortality (OR 0.89 (0.28-2.85); p=0.84) or 5-year survival (HR 0.71 (0.37-1.36); p=0.30). Age, comorbidities, heart failure, Staphylococcus aureus and uncontrolled infection were associated with increased 5-year mortality in BAV patients. CONCLUSION: BAV is frequent in adults with native aortic valve IE. Patients with BAV IE incur high risk of abscess formation and require early surgery in almost three-quarters of cases. IE is a severe complication in the setting of BAV and warrants prompt diagnosis and treatment.

In-hospital mortality and prognostic factors in patients admitted for new-onset heart failure with preserved or reduced ejection fraction: a prospective observational study.

INTRODUCTION: Heart failure (HF) is associated with high morbidity and mortality. A significant component of HF-related adverse outcome occurs during hospitalization. Objective. - To assess features and in-hospital outcomes of patients hospitalized for a first episode of HF. METHODS: We prospectively recruited 799 consecutive patients hospitalized for a first episode of HF during 2000 in the Somme department (France). We evaluated in-hospital mortality in this cohort, identified factors predictive for hospital death, and compared the mortality in patients with preserved or reduced ejection fraction (EF). RESULTS: The mean age of the study population was 75+/-12 years. EF, assessed in 662 patients (83%), was preserved (> or = 50%) in 56% of cases. During hospitalization, 64 deaths (8%) were recorded. The major causes of in-hospital death were acute pulmonary oedema (50%) and cardiogenic shock (22%). Coronary artery disease, low systolic blood pressure on admission, increased heart rate on admission, renal failure, reduced EF (<50%) and older age were identified as independent predictors of in-hospital mortality. Patients with preserved EF were older and comprised a greater proportion of women. In-hospital mortality of the reduced EF group was higher than that of the preserved EF group (8.2% versus 2.7%, p=0.002). On multivariable analysis, reduced EF was independently associated with in-hospital death (odds ratio 2.32; 95% confidence interval 1.06-5.11; p=0.03). In propensity-matched patients, in-hospital mortality was higher in the reduced EF group (7.6% versus 2.2% p=0.02). CONCLUSION: The in-hospital outcome of patients admitted for new-onset HF is poor. Patients with preserved EF are older but have lower in-hospital mortality.

Prognostic impact of diabetes mellitus in patients with heart failure and preserved ejection fraction: a prospective five-year study.

OBJECTIVE: To evaluate the prognostic impact of diabetes mellitus (DM) in patients with heart failure and preserved ejection fraction (HFPEF) DESIGN: A five-year prospective observational study SETTING: Population of 368 consecutive patients from 11 healthcare establishments PATIENTS: All patients hospitalised for a first episode of HFPEF in 2000 in the Somme department, France. INTERVENTIONS: Diagnosis of heart failure (HF) was validated during the index hospitalisation by two independent cardiologists. Diabetic and non-diabetic groups were compared. After discharge, patients were managed by the general practitioner or referring cardiologist. MAIN OUTCOME MEASURES: Overall and cardiovascular mortality. RESULTS: The 96 diabetic patients (26%) were younger and had a higher prevalence of clinical coronary artery disease (CAD) than non-diabetic patients. Patients with DM had higher discharge prescription rates of angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, nitrates and statins. During the five-year follow-up, 208 patients died (43.5%). DM was a potent independent predictor of five-year overall mortality (HR 1.77, 95% CI 1.27 to 2.48, p = 0.001). Compared to the expected survival of the age-matched and gender-matched general population, the five-year survival of patients with DM was dramatically lower (32% vs 79%). The five-year relative survival (observed/expected survival) of diabetic patients was lower than that of the non-diabetic group (41% vs 68%). Cardiovascular causes were responsible for >60% of deaths in the DM group. DM was associated with an increased risk of death in patients with clinical CAD (HR 1.82, 95% CI 1.02 to 3.25, p = 0.04), as well as in patients without clinical CAD (HR 1.85, 95% CI 1.22 to 2.82, p = 0.004). CONCLUSION: In patients with HFPEF, DM is a strong predictor of poorer long-term survival.

Impact of early surgery on 6-month outcome in acute infective endocarditis.

BACKGROUND: The mortality in acute infective endocarditis (IE) remains high. Data on results of early surgery are limited. The aim of our study was to determine whether early surgery is associated with reduced 6-month mortality in a large cohort of acute IE. METHODS AND RESULTS: 310 consecutive patients examined by transthoracic and transoesophageal echocardiography (229 males; mean age: 60+/-15) with definite IE according to Duke criteria were prospectively enrolled. Early surgery was performed in 106 (34%) patients (37 mechanical prosthesis, 32 biological prosthesis, 19 valve repairs, 15 pace maker line extractions, three multiple valve replacements) with an operative mortality of 5,7%. The mean time between admission and early surgery was 12+/-9 days. Early surgery was performed more frequently in patients with heart failure (48% vs 33%, p=0.009), uncontrolled infection (40% vs 23%; p=0.002), abscess (35% vs 18%; p=0.001), neurological event (34% vs 20%; p=0.005), embolic event (50% vs 34%; p=0.006), severe regurgitation (60% vs 29%; p=0.001) and large vegetation (>15 mm) (50% vs 23%; p<0.001). In unadjusted analysis, early surgery was associated with lower 6-month mortality (24% vs 37%; p=0.045). After adjustment of variables associated with mortality and comorbidity index, early surgery was identified as an independent predictor of reduced 6-month mortality (HR=0.52; IC 95%=0.2-0.9; p=0.025). CONCLUSION: Early surgery performed in 34% of patients is independently associated with reduced mortality and should be considered in selected cases to improve outcome in acute IE.

Leptotrichia endocarditis: report of two cases from the International Collaboration on Endocarditis (ICE) database and review of previous cases.

Leptotrichia species typically colonize the oral cavity and genitourinary tract. We report the first two cases of endocarditis secondary to L. goodfellowii sp. nov. Both cases were identified using 16S rRNA gene sequencing. Review of the English literature revealed only two other cases of Leptotrichia sp. endocarditis.

[The best of echocardiography in 2006]. / L'essentiel de 2006 en échocardiographie.

In recent years, Doppler echocardiography has undergone significant technological advances, resulting in spectacular improvements in diagnosis and quantification. This review summarises the advances made in 2006 in fields as varied as cardiac resynchronisation, cardiac failure with preserved systolic function, contrast echocardiography, 3D echocardiography and echocardiographic evaluation of valvular heart disease. Despite growing competition, but mostly complementarity with CT scan and MRI, Doppler echocardiography remains the keystone of cardiological rationale based on non-intensive investigations.

Treatment practices in heart failure with preserved left ventricular ejection fraction: a prospective observational study.

BACKGROUND: Current guidelines for treatment of patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) are empirical. One of the objectives of the ETICS study was to evaluate medical treatment at discharge and after 1 year in patients hospitalised for a first episode of HF in 2000. We report the results concerning treatment of patients with preserved LVEF at discharge and at 1 year. METHODS: Two hundred and sixty three consecutive patients (75+/-10 years, 47 males) with LVEF >50% hospitalised for a first episode of HF were prospectively included. Mean LVEF was 63+/-8%. The main aetiology was hypertension (61%) followed by ischaemic heart disease (29%). Atrial fibrillation and diabetes were present in 34% and 27% of cases, respectively. Medical treatment records were complete at discharge and at 1 year after discharge. RESULTS: At discharge, as at 1 year after discharge, diuretics were the drugs most commonly prescribed (81% and 78%), followed by ACE inhibitors (49% and 46%), amiodarone (32% and 28%), beta-blockers (27% and 29%), nitrates (28% and 27%), calcium channel blockers (27% and 26%), spironolactone (21% and 25%), cardiac glycosides (19% and 24%), and angiotensin II receptor antagonists (4% and 6%). Once prescribed at hospital discharge, drug prescription rates and daily doses did not change significantly over time. Age did not influence drug prescription rates at discharge or at 1 year, except for the spironolactone prescription rate, which decreased at 1 year in patients > or =75 years of age. At discharge, ACE inhibitor and beta-blocker daily doses were lower in older patients, while, at 1 year, no differences in daily doses of these drugs were observed between patients above and below the age of 75 years. CONCLUSION: Loops diuretics are largely prescribed in HF with preserved LVEF, followed by ACE inhibitors. Future large multicentre trials are required to define the background standard treatment in addition to treatment of aetiological factors.

[Prevention of calcific aortic stenosis by statins: myth or reality?]. / Prevention de la sténose aortique calcifiée par les statines: mythe ou réalité?

Degenerative calcific aortic stenosis is the most common valvular disease in the industrialised world. During the last decade, experimental studies have improved our understanding of the physiopathology of this disease. The latest data concerns the demonstration of the mode of installation and progression which resembles that of athrosclerosis. Lipid abnormalities, especially hypercholesterolaemia, are important in the initiation of the valvular lesions and also in the calcification of the aortic orifice. Experimental data and retrospective clinical studies suggest, but without proof, that statins could slow th progression of the aortic stenosis. However, the first prospective trial, recently published, questions this hypothesis. Randomised multicenter trials are currently under way and should provide the answer to the role of stetins in the prevention of aortic stenosis.

[The best of echocardiography in 2005]. / L'essentiel de 2005 en échocardiographie.

Echocardiography continues to evolve in several directions: on the technical front, various tools are being developed and real time 3D is starting to find a place in routine practice as much as contrast is used unequally depending on the country. On the diagnostic front, certain aspects have been particularly emphasised this year: The key role of quantification of valvulopathies in order to guide management, both at rest and on effort. The place of echocardiography in asynchronism, even if a more consensual strategy is needed to take into account the different approaches. The very good prognostic series on stress echography in the context of myocardial ischaemia. Advances in the evaluation of filling pressures have allowed a better definition of the limits, and have refined the understanding of so-called 'diastolic' cardiac failure. Finally, the role of echography to guide and also evaluate the results of foramen ovale or interatrial communication closure.

Heart failure due to left ventricular systolic dysfunction: treatment at discharge from hospital and at one year.

BACKGROUND: The treatment of heart failure (HF) due to left ventricular systolic dysfunction has been defined in recent guidelines, but these guidelines are not always applied in routine clinical practice. One of the objectives of the ETICS study was to evaluate medical treatment at discharge and after 1 year in patients hospitalised for a first episode of congestive HF due to left ventricular systolic dysfunction in 2000. METHODS: One hundred and seventy nine patients (63% males, mean age of 69+/-13 years) with an ejection fraction < or = 40% were prospectively included. The main aetiology was ischaemic heart disease (44%). RESULTS: The drugs prescribed at discharge and at one year, respectively, were loop diuretics in 95% and 91% of cases, angiotensin-converting enzyme (ACE) inhibitors in 82% and 75%, spironolactone in 35% and 37%, beta-blockers in 25% and 41%, digitalis glycosides in 34% and 30% of cases, and nitrates in 20% and 16% of cases. ACE inhibitors were prescribed at discharge and at 1 year at dosages reaching 64+/-29% and 72+/-30% of the recommended doses, respectively, and beta-blockers were prescribed at 26+/-16% and 35+/-25% of recommended doses, respectively. CONCLUSION: Diuretics and ACE inhibitors are largely prescribed in HF due to left ventricular systolic dysfunction, followed by spironolactone. Beta-blockers are still underused both in terms of the rate of patients receiving them and the daily doses. These results highlight the value of continuing to widely circulate official practice guidelines in order to improve the management of HF due to left ventricular systolic dysfunction.

[Contrast echocardiography: from diagnosis to treatment]. / Echocardiographie de contraste: du diagnostic à la thérapeutique.

Contrast echocardiography is widely used in echocardiographic laboratories. When used at rest or with a stress test, it provides complementary information concerning myocardial perfusion not available with conventional imaging. Its applications in the evaluation of left ventricular ejection fraction, the detection of coronary stenosis and the no reflow phenomenon in acute myocardial infarction have been validated. Advances in our understanding of the interaction between the microbubbles and ultrasound have led to considering the microbubble not just as a vascular tracer but also as a vector of active molecules. The detection of angiogenesis, thrombi, or intravascular inflammation are possible with contrast echocardiography. Therefore, new perspectives in myocardial contrast echo are opening up in therapeutics. Preliminary studies in the animal suggest that it may be possible to use microbubbles to deliver drugs or genetic material to the heart of the cardiomyocytes.

[Value of coronary reserve flow measurement by transthoracic echocardiography]. / Intéret de la mesure du flux et de la réserve coronaire par échographie trans-thoracique.

The measurement of coronary reserve flow by transthoracic echocardiography of the left anterior descending and the posterior interventricular artery is a new non-invasive reproducible and attractive method which can be performed at the bedside with the proviso of a specific learning curve. The potential value is great: detection of significant (> 70%) coronary stenosis, coronary occlusion, post-angioplasty follow-up, evaluation of intermediate stenoses, coupling with stress echo, reperfusion studies, no reflow detection, post-infarction viability, coronary bypass patency and studies of microcirculation.

[When should one operate for severe asymptomatic aortic stenosis?]. / Quand opérer une sténose aortique serrée asymptomatique?

The most common cause of aortic stenosis is degenerative and progression of the disease is slow. Deciding to proceed to aortic valve replacement in an asymptomatic patient is always difficult. Only a minority will require valve replacement after repeated work-ups including stress testing and serial echographic examinations. In the future, stress echocardiography and BNP measurements may prove helpful in decision making.

Comparison of clinical and morphological characteristics of Staphylococcus aureus endocarditis with endocarditis caused by other pathogens.

OBJECTIVES: To analyse clinical, echocardiographic, and prognostic characteristics of Staphylococcus aureus infective endocarditis (IE) compared with endocarditis caused by other pathogens. DESIGN: Cohort study. METHODS: 194 consecutive patients with definite IE according to the Duke criteria prospectively examined by transthoracic and transoesophageal echocardiography were enrolled. Patients without identified microorganisms were excluded. The S aureus IE group (n = 61) was compared with the group with IE caused by other pathogens (n = 133). RESULTS: Compared with IE caused by other pathogens, S aureus IE was characterised by severe co-morbidity, a shorter duration of symptoms before diagnosis, and a higher prevalence of right sided IE, cutaneous portal of entry, and history of renal failure. Severe sepsis, major neurological events, and multiple organ failure were more frequent during the acute phase in S aureus IE. In-hospital mortality (34% v 10%, p < 0.001) was higher in patients with S aureus IE and the 36 month actuarial survival rate was lower in S aureus IE than in IE caused by other pathogens (47% v 68%, p = 0.002). Multivariate analyses identified S aureus infection as a predictive factor for in-hospital mortality and for overall mortality. CONCLUSIONS: S aureus IE compared with IE caused by other pathogens occurs in a more debilitated clinical setting and is characterised by a higher prevalence of severe sepsis, major neurological events, and multiple organ failure leading to higher mortality.

Prosthetic valve endocarditis: who needs surgery? A multicentre study of 104 cases.

OBJECTIVES: To identify the prognostic markers of a bad outcome in a large population of 104 patients with prosthetic valve endocarditis (PVE), and to study the influence of medical versus surgical strategy on outcome in PVE and thus to identify patients for whom surgery may be beneficial. DESIGN: Multicentre study. METHODS AND RESULTS: Among 104 patients, 22 (21%) died in hospital. Factors associated with in-hospital death were severe co-morbidity (6% of survivors v 41% of those who died, p = 0.05), renal failure (28% v 45%, p = 0.05), moderate to severe regurgitation (22% v 54%, p = 0.006), staphylococcal infection (16% v 54%, p = 0.001), severe heart failure (22% v 64%, p = 0.001), and occurrence of any complication (60% v 90%, p = 0.05). By multivariate analysis, severe heart failure (odds ratio 5.5) and Staphylococcus aureus infection (odds ratio 6.1) were the only independent predictors of in-hospital death. Among 82 in-hospital survivors, 21 (26%) died during a 32 month follow up. A Cox proportional hazards model identified early PVE, co-morbidity, severe heart failure, staphylococcus infection, and new prosthetic dehiscence as independent predictors of long term mortality. Mortality was not significantly different between surgical and non-surgical patients (17% v 25%, respectively, not significant). However, both in-hospital and long term mortality were reduced by a surgical approach in high risk subgroups of patients with staphylococcal PVE and complicated PVE. CONCLUSIONS: Firstly, PVE not only carries a high in-hospital mortality risk but also is associated with high long term mortality and needs close follow up after the initial episode. Secondly, congestive heart failure, early PVE, staphylococcal infection, and complicated PVE are associated with a bad outcome. Thirdly, subgroups of patients could be identified for whom surgery is associated with a better outcome: patients with staphylococcal and complicated PVE. Early surgery is strongly recommended for these patients.

Superiority of surgical versus medical treatment in patients with Staphylococcus aureus infective endocarditis.

BACKGROUND: We present here the clinical features and outcome of 54 patients affected by a Staphylococcus aureus infective endocarditis at the Amiens hospital between 1990 and 2000. The patients operated-on, group A (20 patients), were compared to the population of patients treated by exclusive antibiotherapy, group B (34 patients). PATIENTS AND METHOD: The male gender predominated with a sex ratio of 2.6. The mean age of the global population was 58.7+/-1.6 years. Time between onset of endocarditis symptoms and treatment (entire group) ranged from 1 to 120 days (mean 14.4 days). The main portal of entry were, respectively, for group A and group B: cutaneous 55% and 44.1%; intravascular material 5% and 8.8%; and rhinopharynx 5% and 8.8%. Seventy-five percent of the Staphylococcus aureus isolated were Methi-S. The main surgical treatment indication were: hemodynamic failure (HF) (30%), unstable infection with collapse (UI) (30%), UI+HF (10%), voluminous vegetation (20%) and embolism event (10%). RESULTS: The hospital mortality rate were respectively for the entire group, group A and group B: 25%, 35% and to 41% (ns). For group A, the operative mortality was lower(21%) after the first week. The actuarial survival rate (Kaplan-Meier) after 24 months was 54./+/-6.9% for the global population and 74+/-10.6% for group A and 43+/-8.5 for group B (p<0.001). The multivariate analysis finds severe sepsis and index of comorbidity as independent factors related to the global late mortality and, respectively, the age and the severe sepsis for group A, and the cardiac insufficiency for group B. CONCLUSION: The surgical treatment seems to be the best way to improve the results after Staphylococcus aureus endocarditis. The severity of the sepsis remains the most severe prognostic element, whatever the treatment adopted may be.

[The best of echocardiography in 2004]. / L'essentiel de 2004 en échocardiographie.

What major trends can we single out from the large amount of literature that appeared in 2004? The role of echography in the investigation of asynchronism has most certainly been better defined. Real time 3D echography, now routinely available, has started to gain respect in different pathologies. The place of filling pressure evaluation in patients' management, as much diagnostic as therapeutic, has again been refined. The prognostic contribution of stress echography has been emphasized in particular this year. Despite a still limited routine role, publications regarding contrast techniques have been quite numerous: not only diagnostic contrast echography, but also contrast and pleiotropic gene transfer in the myocardium. The study of coronary reserve via the transthoracic route, possibly assisted with contrast, should become established as a routine technique.

Impact of inflammation and oxidative stress on vascular calcifications in chronic kidney disease.

Vascular and/or valvular calcifications in patients with chronic kidney disease (CKD) appear to indicate a poor prognosis in terms of overall survival and cardiovascular morbidity and mortality. Inflammation and oxidative stress represent new features of the arterial and/or valvular calcification process. However, only limited observational and epidemiological data are available in these areas. Therefore, the link between inflammation, oxidation and vascular and/or valvular calcifications deserves careful consideration in CKD patients, since they may become targets for the development of new therapeutic strategies.