[An exceptional case of tricuspid infective endocarditis due to Bartonella henseale revealed by an old pulmonary embolism]. / Un cas exceptionnel d'endocardite infectieuse tricuspide à Bartonella henselae révélée par une embolie pulmonaire « vieillie ¼.

We report a case of blood culture-negative tricuspid infective endocarditis revealed after tick bite by repeated pulmonary infection during one year due to septic pulmonary emboli in a 67-year-old farmer woman. Tricuspid vegetation and pulmonary emboli are calcified. Lyme serology is negative. Serologic test and PCR analysis are positive to Bartonella henselae. The evolution is favorable after antibiotic and anticoagulant treatment. Infective endocarditis due to B. henselae is an exceptional complication of cat scratch disease. You have to think about in case of blood culture-negative endocarditis with calcified valvular lesions even without cat bite, tick seems to be vector of the bacteria.

[Timing and indications for surgical intervention in infective endocarditis]. / Indications et moment de l'intervention chirurgicale dans l'endocardite infectieuse.

This paper reviews current knowledge on the indications for and timing of cardiac surgery in patients with infective endocarditis. The main indications for surgery are haemodynamic compromise, persisting infection, peripheral embolisation, large size of vegetations, large valvular and paravalvular damage and infections caused by certain microorganisms.

[The best of valvular heart disease in 2006]. / L'essentiel de 2006 des valvulopathies.

In the field of valvular diseases, the year 2006 has been above all marked by the publication of new joint AHA/ACC guidelines. Besides, other publications included severe aortic stenosis, drug therapy in chronic aortic regurgitation, the indications for surgery in asymptomatic mitral regurgitation, as well as valve surgery in the elderly and mismatch severity after aortic valve replacement. In a series of 66 cases of aortic stenosis with poor LV function undergoing stress echocardiography, it has been shown that whether the absence of contractile reserve identifies a high-risk subgroup for aortic valve replacement (33% vs. 6%), this exam does not predict the functional prognosis and the post-operative LV function improvement. Hence, the absence of contractile reserve should not contra-indicate aortic valve replacement surgery, even though the prognosis is severe, since the natural prognosis is extremely severe. The question of aortic valve replacement in case of mild stenosis with the indication of CABG remains difficult. Taking into account the important mortality of redo surgery, a study was in favor of a systematic aortic valve replacement associated to CABG in patients <75 years who had a mean aortic gradient > 30 mmHg, a LVH and aortic valve calcifications. Old patients (>80 years) with severe aortic stenosis have a very severe natural prognosis, authorizing wide indications for aortic valve replacement, in the absence of important comorbidities. The use of vasodilators in severe chronic aortic regurgitation remains debated. In a randomized study comparing Nifedipine 40 mg vs. Enalapril 20 mm vs. placebo, it has been shown that the use of a vasodilator does not modify the time of valvular surgery at all. After a mean follow-up of 7 years, the rates of aortic valve replacement were identical in the 3 groups, and there wa no difference regarding the preoperative regurgitation volume, LV dimensions and mass, and LVEF. The timing for huge chronic and asymptomatic mitral regurgitation remains debated, even though the present trend is to prefer early surgery, due to the risk of sudden death. A new study evidenced the interest of clinical and echocardiographic surveillance on a prospective series of 129 consecutive asymptomatic patients with severe degenerative mitral regurgitation. The surgical indication was only based on the occurrence of symptoms, an echographic LV diameters increase, a LV dysfunction, the presence of pulmonary hypertension or atrial fibrillation. At 8 years, the overall mortality was at 91 + 3%, with a survival rate not statistically different from the expected rates; 35 patients have been operated. The 6-years and 8-years surgical indication-free survival were respectively at 65 +/- 5% and 55 +/- 6%, with a null operative mortality, and favorable data regarding post-operative survival, symptoms and LV function. The indication for surgical correction of mitral regurgitation in the elderly remains a difficult problem, due to the surgical risk. The Mayo Clinic team analyzed the evolution of 284 patients > 75 years operated for mitral regurgitation between 1980 and 1995, compared to younger subjects (65 - 74 years old, n=504, and <65 years, n=556). The age-adjusted 5-years survival was lower in the older patients, but the age-adjusted observed/estimated survival ratios were similar in the different age groups. The perioperative risk, significantly higher in the older patients (p<0.001) decreased systematically for all age ranges in the most recent periods (the 1980-83 period vs. 1992-95), from 27% to 5%, 21% to 4%, and 7% to 2% respectively in patients > 75 years, 65-74 years and <65 years. An age >75 years was an independent predictive factor for the surgical mortality. These data show that, despite the surgical risk, the surgical treatment of mitral regurgitation should be extended to the oldest patients. One of the most surprising information provided in the ACC/AHA guidelines is the necessity of adding a daily dose of 75 to 100 mg of aspirin systematically to VKA in patients with mechanical prosthetic valves or in those with a valvular bioprosthesis with one or several risk factors for thrombo-embolic events (AF, history of thromboembolic event, LV dysfunction, hypercoagulable state). This major recommendation (Class 1, level of evidence B) appears surprising, since it is not actually based on definite results issued from randomized studies using these doses of aspirin. According to these guidelines, this association not only reduces the risk of thrombo-embolic events in patients with valvular prosthesis, but also decreases the mortality related to other cardiovascular causes (especially coronary artery disease), with the cost of a minimal risk augmentation for hemorrhagic complications. The importance of pejorative prognosis of mismatch (defined as an inadequacy between the aortic orifice size and patient's body surface after aortic valve replacement) has been subject to several publications this year. The substantial increase of post-operative events and poor survival in patients with this mismatch imply adapted preventive strategies in terms of selection of diameters and type of aortic valvular prosthesis and associated aortic surgical techniques (such as annular enlargement or supra-annular position).

[The best of valvular heart disease in 2005]. / L'essentiel de 2005 des valvulopathies.

The year 2005 has been rich in publications concerning valvular heart disease. In France, this year has been dominated by the publication of the French Society of Cardiologists' guidelines on the operative and interventional indications for acquired valvular heart disease: discussed and accepted formal indications based on the evidence in the literature. Non-ischaemic mitral insufficiency has been the subject of a major study that showed the high prognostic significance of echographic measuring of the area of the regurgitating orifice; patients with a surface > or =40 mm2 had a worse long-term prognosis and should undergo surgery early. The prognostic significance of BNP in valvular heart disease, such as mitral insufficiency and aortic stenosis, also became apparent. BNP is being used more and more for risk stratification for these conditions. The significance of anti-arrhythmic surgery combined with a mitral procedure has confirmed the harmful effect of atrial fibrillation, before and after the mitral surgery. The first randomised study into the use of statins to slow the progression of aortic stenosis was unfortunately disappointing, despite the various unrandomised studies that had opened a therapeutic pathway for this pathology, for which the prevalence is continually rising due to the ever increasing life expectancy. In mitral stenosis, a randomised study showed the long-term value of mitral commissurotomy in percutaneous mitral valvuloplasty, giving identical long-term results, in terms of mitral area, to those obtained with the classic Inoué balloon. In infectious endocarditis, surveys have confirmed the seriousness of this pathology as well as the slight advances in its prophylaxis. Other studies have confirmed the frequency and the severity of emboli, endocarditis due to Staphylococcus aureus, and the low risk of recurrence for endocarditis with the more and more accepted short course antibiotic treatment for patients undergoing surgery. Of course, this selection of publications is limited and by necessity subjective.

[Pathophysiology and therapeutic implications of left heart failure]. / Données physiopathologiques et implications thérapeutiques au cours de l'insuffisance cardiaque gauche.

PURPOSE: Heart failure is the ultimate step of most cardiovascular diseases. Its frequency increases regularly because of the progressive increase of life expectancy and better management of cardiovascular diseases. The prognosis is very poor (5-year mortality: 50%) as is quality of life; heart failure is a very costly disease. CURRENT KNOWLEDGE AND KEYS POINTS: Aims of treatment are improvement of symptoms and thus improvement of quality of life and increase of survival. The treatment systematically combines: general advice, dietary measures; medical treatment (with betablockers, ACE inhibitors and/or angiotensin II receptor antagonists, diuretics, in some cases aspirin or oral anticoagulants, digitalis and amiodarone) according to severity of heart failure, presence of congestion, aetiology, age; etiologic treatment if possible; treatment and prevention of precipitating and exacerbating factors. According to clinical and paraclinical features, one may propose cardiac multisite stimulation, cardiac surgery, physical stress training and cardiac transplantation. In order to decrease frequency of heart failure, prevention of cardiovascular diseases which lead to heart failure must be done as often is possible (hypertension, valvular heart disease, ischemic heart disease). FUTURE PROSPECTS AND PROJECTS: The future of the treatment of heart failure is the multidisciplinary management of heart failure (networks) led by hospital units specialized in heart failure.

[The best of valvular heart disease in 2004]. / L'essentiel de 2004 des valvulopathies.

The year 2004 was rich in publications concerning valvular heart disease. Infectious endocarditis was the subject of guidelines on prevention, diagnosis and therapeutic management under the aegis of the European Cardiology Society. There was much study on aortic pathology: the results appear to slow the progression of the severity of aortic stenosis. Furthermore, MRI can be advocated when there is a conflict in the measurement of the aortic area in aortic stenosis as determined by non invasive methods. This year was also marked by the first experiences of transcutaneous implantation of a prosthetic aortic valve in patients considered inoperable. Mitral insufficiency has also been studied: operative indications, incidence and prognosis of early and late post-operative atrial fibrillation and the significance of ischaemic mitral insufficiency, for which the prognosis remains poor. Lastly, the diagnosis and management of prosthesis thrombosis were studied and in particular the contribution of thrombolysis. Of course, this analysis is limited, and many studies have not been included in this selection.

[Propionibacterium acnes infective endocarditis. Study of 11 cases and review of literature]. / Endocardites infectieuses a Propionibacterium acnes. Etude de 11 cas et revue de la littérature.

BACKGROUND: Propionibacterium acnes, a gram positive, anaerobic, skin commensal bacillus, is too often considered a biologic fluid contaminant, of blood cultures in particular. Its implication has been shown in various infections, including brain abscess, ocular infections, osteitis, and acne. It is also the cause of infective endocarditis (IE). METHODS: Retrospective, observational study of 11 patients with P. acnes IE, hospitalised between 1993 and 2001 at the Louis Pradel Hospital, Lyon-Bron, and review of 20 published cases. RESULTS: P. acnes IE is rare, though its prevalence is probably underestimated. It is most likely to affect men (71%), and affects all ages (children 4/31 cases). An entry point, probably cutaneous, is rarely confirmed. P. acnes IE often develops on valve prosthesis (42%), and embolisms are common (61%). The infective site is usually aortic (55%). The often-subtle symptoms and slow growth of the organism in vitro complicate the diagnosis, which is often made at a late stage, when valvular and peri-valvular destruction has become major. Despite the high sensitivity of P. acnes to most antimicrobials, a surgical intervention is very often needed (81%). The mortality is relatively high (15% to 27%). Examination of pathologic specimens by polymerase chain reaction increases the sensitivity and speed of its detection. The identification of P. acnes in a biologic specimen, valvular tissue in particular, requires a thorough knowledge of the clinical context before concluding to contamination, and mandates close surveillance of the patient. P. acnes can be the cause of IE long before it has been detected.

[Sudden death by coronary spasm: a particular and often unrecognised clinical entity]. / Mort subite par s pasme coronaire: une entité particulière, trop souvent méconnue.

The authors report 3 cases of resuscitated sudden death in which the investigations clearly showed coronary spasm. This was demonstrated by systematic coronary angiography with an ergometric test. Two patients underwent electrophysiological investigations which were normal. The three patients were prescribed long-term calcium antagonist therapy and one of them underwent coronary angioplasty. With a follow-up of 6 months to 3 years, there was no clinical recurrence or documented arrhythmia. A review of the literature shows that this is a cause of sudden death which is probably underestimated and unrecognised. Electrophysiological investigations often give disappointing results and medical therapy is the keystone of treatment. Coronary angioplasty and implantation of an automatic defibrillator are second-line treatments reserved to forms refractory to medical therapy.

[Coronary pressure measurement for functional evaluation and treatment of intermediate angiographic stenosis]. / Apport des guides de pression intracoronaire pour l'évaluation fonctionnelle et le traitement des sténoses angiographiques intermédiaires.

Accurate understanding of the physiopathology of a coronary stenosis is a major objective in management during diagnostic coronary angiography. Measurement of fractional flow reserve (FFR) by coronary pressure measurement is a reliable method for evaluating the functional consequences of a lesion of the myocardium. This retrospective monocentric study of 114 patients showed that routine coronary pressure measurement for assessing the functional consequences of intermediate (30 to 70% stenosis) lesions or those of ambiguous topography: was necessary in 4% of diagnostic coronary angiographies enabling an immediate management decision. Using this method, 34% of complementary investigations were not performed (stress test, myocardial scintigraphy, dobutamine stress echocardiography). Seventeen per cent of unnecessary angioplasties were also avoided so that acute coronary event were also avoided when lesions with a FFR >0.75 were not treated by angioplasty. A 10-14% reduction in cost was achieved compared with a strategy of systematic angioplasty in respectively mono- or multivessel disease patients and 39% compared with performing ambulatory myocardial scintigraphy in patients with multivessel disease.

[Heart failure and myocardial infarction in the elderly. For its more specific management]. / Insuffisance cardiaque et infarctus myocardique chez le sujet âgé. Pour une prise en charge plus déterminée.

UNLABELLED: TWO NEGATIVE FACTORS: Heart failure, whether present during the first hours of myocardial infarction, whether it worsens or whether it occurs during the first days, or persists during the acute phase, is a highly unfavourable predictive factor of hospital mortality and mortality secondary to myocardial infarction. Furthermore, old age is the most negative predictive factor of late mortality following myocardial infarction. THERAPEUTIC IMPLICATIONS: These two negative predictive elements that considerably enhance immediate and secondary mortality after myocardial infarction, notably when they are combined, require more specific and voluntary management (in terms of medical--thrombolysis, beta-blockers, CEI--and interventional treatments) in these patients. THE NEED TO EXTEND THE INDICATIONS: Since the efficacy of these medical treatments and myocardial revascularisation techniques (during the acute phase in the case of contraindication for thrombolysis or during the secondary phase) is even greater, in terms of immediate and secondary mortality after myocardial infarction in patients at high risk (elderly patients and those suffering from heart failure), it would appear essential to widen their indications to this group of patients in whom the spontaneous prognosis is worst.

[Worsening of heart failure during hospital course in myocardial infarction is a factor of poor prognosis. Apropos of a prospective cohort study of 2,507 patients hospitalized with myocardial infarction: the PRIMA study]. / L'aggravation de l'insuffisance cardiaque durant la phase hospitalière d'un infarctus myocardique est un facteur de mauvais pronostic. A propos d'une cohorte prospective de 2,507 patients hospitalisés pour infarctus myocardique: l'étude PRIMA.

BACKGROUND: Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon. AIMS: The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of heart failure worsening, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the "real world" in a region in France, using multivariate analysis. METHODS: Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône-Alpes region in France between September 1, 1993 and January 31, 1995. RESULTS: Among 2,507 patients, 33% were in Killip classes II-IV at admission. Four hundred and sixteen patients (17%) had worsening of Killip class during the first five days. In-hospital mortality (overall: 14%) increased dramatically with Killip class at admission (9% in class I; 62% in class IV) and with worsening of Killip class during the first five days (36% vs 8% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first five days. CONCLUSION: This large, unselected cohort revealed that among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

Should we still perform angioplasty and stenting of an unprotected left main coronary artery stenosis in heart transplant patients? Two new cases and a review of the literature.

Coronary balloon angioplasty with stent implantation has emerged as a possible alternative to bypass grafting or repeat transplantation in left main coronary stenosis in heart transplant patients. We report 2 new cases of stent implantation for unprotected and isolated left main stenosis in heart transplant patients. Despite an initially successful procedure, restenosis prompted the performance of bypass surgery in both patients. The relative advantages and disadvantages of available techniques of revascularization are discussed in the context of the literature.

[Efficacy and safety of low-dose heparin (30 IU/kg) during coronary angioplasty]. / Efficacité et sécurité d'emploi de faibles doses d'héparine (30 UI/kg) en cours d'angioplastie coronaire.

High doses of heparin are recommended during coronary angioplasty although platelet inhibition seems to play a role in the prevention of ischaemic complications. Low dose heparin could reduce the incidence of local complications without increasing that of major coronary events. The authors report the results of a prospective register of coronary angioplasties performed by the femoral approach with a single bolus of 30 IU/Kg of heparin and immediate withdrawal of the 6 French introducer. Only patients with recent infarction or left main stem disease were excluded. All underwent clinical examination and ultrasonic scanning of the puncture site the day after the procedure. Four hundred and eighteen patients were included (mean age: 63.3 +/- 11 years; 79% men; 77% stenting). The average dose of heparin was 2253 +/- 1056 IU; the average procedure time was 25 +/- 16 minutes, and a final activated clotting time was 174 +/- 69 ms. The duration of normal compression was 7.7 +/- 3 min. Eighty-three point five per cent of patients were discharged the day after the procedure with a global cardiovascular complication rate of 2.87%. At 1 month, 1.67% of secondary cardiovascular events was recorded. Ultrasonography of the puncture site was abnormal in 7.6% of patients. Only one serious vascular complication (0.24%) requiring transfusion and surgical repair, was observed. The authors conclude that the use of low dose heparin appears effective and safe in cases without acute myocardial infarction. This protocol allows faster mobilisation and earlier hospital discharge of patients.

Indicators of myocardial dysfunction and quality of life, one year after acute infarction.

BACKGROUND: There remains controversy concerning the association between myocardial dysfunction diagnosed soon after acute myocardial infarction (AMI), and subsequent quality of life. AIMS: We searched for a correlation between criteria of myocardial dysfunction assessed within the first month after AMI, and quality of life perceived 1 year later. METHODS: Six hundred and seventy-one patients were followed up and quality of life was assessed using the Nottingham Health Profile. Spearman correlation was used for univariate analyses. A logistic regression identified independent predictors of impaired quality of life. RESULTS: Patients perceiving inferior quality of life were 61% for energy, 61% for sleep, 49% for physical mobility, 49% for pain, 63% for emotional reactions, and 28% for social isolation. Impaired quality of life was not associated with the initial Killip class. A low ejection fraction was associated with impaired physical mobility (OR=1.21, 95% CI=1.05-1.39). Presence of abnormally contracting myocardial segments was associated with impaired mobility (1.40, 1.09-1.80) and with increased pain (1.30, 1.02-1.66). The presence of diseased coronary vessels was associated with pain (1.25, 1.06-1.46). CONCLUSION: Myocardial dysfunction was generally associated with impaired quality of life. This has to be considered when assessing improvement of quality of life after medical or surgical treatment of AMI.

Thrombolysis in myocardial infarction in a prospective cohort of 2,515 consecutive patients: older age and longer delays lead to a lower thrombolysis rate.

OBJECTIVE: This prospective study sought to determine the rate of thrombolysis in myocardial infarction and the factors that influenced it in everyday practice. METHODS AND RESULTS: Data were prospectively collected in all patients admitted in all (48) university, community, and private hospitals in three departments in the Rhjne-Alpes region in France between September 1, 1993 and January 31, 1995. Data from 2,515 patients were included. Overall, 36% of the patients received thrombolysis. The decrease of the thrombolysis rate with age was very regular. The difference between men and women disappeared almost completely when age was taken into account in a bivariate analysis. Among 19 variables introduced in the logistic regression, only the following ones were significant predictors (odds ratio < 1 means less thrombolysis): age (odds ratio: 0.60 per decade), administrative department, type of hospital (community/tertiary: 0.74; private/tertiary: 0.58), history of myocardial infarction or of angina pectoris (0.67), location of myocardial infarction (Q wave non anterior/Q wave anterior: 0.75; non Q wave/Q wave anterior: 0.18), delay between symptoms onset and first medical intervention (0.06), history of cancer (0.47), and history of psychiatric disorder (0.38). CONCLUSIONS: In France as in other countries, the rate of thrombolysis is low. In order to increase this rate, we have to find ways to be more "aggressive" in older patients, and to precisely describe the health care pathways in order to shorten delays.