[Extensive cardiac thombosis in a patient with disseminated intravascular coagulation]. / Thrombose extensive intracardiaque dans un contexte de coagulation intravasculaire disséminée.

Disseminated intravascular coagulation is a syndrome characterized by thrombin and fibrin generation which is associated with organ failure and death. Intracardiac thrombus may occur and further deteriorate prognosis. We report the case of a patient with massive intraventricular thrombus revealed by an acute ischemia of the upper left limb in a context of pulmonary adenocarcinoma complicated by a disseminated intravascular coagulation. We describe the diagnostic modalities and the fatal evolution.

Major impact of vitamin D3 deficiency and supplementation on left ventricular torsional mechanics during dobutamine stress in uncomplicated type 2 diabetes.

BACKGROUND AND AIMS: Hypovitaminosis D is associated with the risk of diabetic complications. Its role in diabetic-related cardiac abnormalities remain poorly understood. We aimed therefore to evaluate the effect of vitamin D deficiency and supplementation on early left ventricular (LV) dysfunction in vitamin D deficient patients with uncomplicated T2D. METHODS AND RESULTS: Sixty-three consecutive T2D patients who had a diagnosis of vitamin D3 were prospectively recruited and allocated into 2 groups (25(OH)D < 20 ng/mL: VDD, >20 ng/mL VDND). Twenty-eight of them with 25(OH)D < 20 ng/mL benefited from a 3-month supplementation. At baseline and follow-up, after conventional echocardiography including evaluation of epicardial adipose tissue (EAT), both LV longitudinal (LS) and circumferential (CS) strains and rotation/twist mechanics were evaluated at rest and during dobutamine (DOB) stress. After treatment, T2D patients successfully normalized their 25(OH)D levels. The strongest associations between vitamin D deficiency and supplementation with LV myocardial function were noticed for torsional mechanics indexes under DOB. EAT correlated significantly (p < 0.01) with baseline 25(OH)D and was reduced after supplementation. Significant correlations were obtained between these 2 parameters with twist or apical rotation at baseline (p < 0.01) and between their delta changes at follow-up (p < 0.01) under DOB. Significant improvements in LS and CS (p < 0.05) under DOB were also underlined at follow-up, with major enhancements noticed in the apical region (p < 0.01) of the LV. CONCLUSIONS: This study provides the first evidences of the potential of vitamin D supplementation as an efficient prophylactic strategy to alleviate the progression of myocardial dysfunction in asymptomatic patients with uncomplicated T2D. CLINICALTRIALS: NCT03437421.

[Acute myocarditis in a patient with dengue infection]. / Myocardite aiguë induite par la dengue.

Dengue is a febrile viral illness transmitted by Aedes Aegypti mosquito with growing incidence, it could be associated with cardiovascular complication mediated by inflammation and notably acute myocarditis. We report the case of a 36-year old woman admitted in cardiology department with initial diagnosis of acute coronary syndrome and ultimately diagnosed to have an acute myocarditis induced by dengue infection; we describe diagnostic modalities and clinical evolution.

Left ventricular function and mechanics in backs and forwards elite rugby union players.

ABSTRACTPurpose: The aim of the present study was to assess left ventricular (LV) morphological and regional functional adaptations in backs and forwards elite rugby union (RU) players. METHODS: Thirty-nine elite male RU players and twenty sedentary controls have been examined using resting echocardiography. RU players were divided into two groups, forwards (n = 22) and backs (n = 17). Evaluations included tissue Doppler and 2D speckle-tracking analysis to assess LV strains and twisting mechanics. RESULTS: The elite RU players exhibited an LV remodelling characterized by an increase in LV mass indexed to body surface area (82.2 ± 13.2 vs. 99.9 ± 16.1 and 119.7 ± 13.4 g.m-2, in controls, backs and forwards; P < .001). Compared to backs, forwards exhibited lower global longitudinal strain (19.9 ± 2.5 vs. 18.0 ± 1.6%; P < .05), lower early diastolic velocity (16.5 ± 1.8 vs. 15.0 ± 2.3 cm.s-1; P < .05) and lower diastolic longitudinal strain rate (1.80 ± 0.34 vs. 1.54 ± 0.26 s-1; P < .01), especially at the apex. LV twist and untwisting velocities were similar in RU players compared to controls, but with lower apical (-46.2 ± 22.1 vs. -28.2 ± 21.7 deg.s-1; P < .01) and higher basal rotational velocities (33.9 ± 20.9 vs. 48.4 ± 20.7 deg.s-1; P < .05). CONCLUSION: RU players exhibited an increase in LV mass which was more pronounced in forwards. In forwards, LV global longitudinal strain was depressed, LV filling pressures were decreased, and LV relaxation depressed at the apex.Highlights Elite RU players exhibited LV hypertrophy, especially in forwards players.LV regional function suggested a drop in LV relaxation and an increase in LV filling pressures in RU players, with higher alterations in forwards.LV remodelling was associated with regional alterations in torsional mechanics: higher rotations and rotational diastolic velocities at the basal level of LV but lower rotation and rotational diastolic velocities at the apex were observed in RU players.

Additive effects of type 2 diabetes and metabolic syndrome on left ventricular torsion and linear deformation abnormalities during dobutamine stress echocardiography.

Objective: The interplay between metabolic syndrome (MS) and type 2 diabetes (T2D) on regional myocardial mechanics and the potential additional effects of their combination remain poorly understood. In this context, we evaluated left ventricular (LV) torsion and linear deformation at rest and under dobutamine (DB) stress in patients with T2D, MS or both. Methods: Thirty-nine T2D patients without MS (T2D), 37 MS patients free from T2D (MS), 44 patients with both T2D and MS (T2D-MS group) and 38 healthy patients (control group) were prospectively recruited. Speckle-tracking echocardiography (STE) was conducted at rest and low dose DB to evaluate LV myocardial longitudinal (LS) as well as circumferential (CS) strain and early diastolic strain rate (LSrd, CSrd) and twist-untwist mechanics. Results: At rest, MS, T2D and controls presented with similar resting LS and LSrd while significant lower values were obtained in T2D-MS compared to controls. DB revealed reduced LS, LSrd, CS and CSrd in MS and T2D groups compared to controls. In T2-MS, the decline in LS and LSrd established at rest was exacerbated under DB. Stress echocardiography revealed also lower basal rotation and subsequently lower twist in MS and T2D patients compared to controls. T2D-MS showed major impairments of apical rotation and twist under DB stress, with values significantly lower compared to the 3 other groups. From stepwise multiple linear regression analysis, epicardial adipose tissue for Δ (rest to DB) LS, numbers of MS factors for Δ CS and Δ Twist emerged as major independent predictors. Conclusion: These results demonstrate synergic and additive effects of T2D and MS on LV torsion and linear deformation abnormalities in asymptomatic patients with metabolic diseases. They also highlight the usefulness of speckle tracking echocardiography under DB stress in detecting multidirectional myocardial mechanics impairments that can remain barely detectable at rest, such as in isolated T2D or MS patients.

A Thrombus on a Journey: A Massive Thrombus in Transit With Cerebral, Coronary, and Pulmonary Embolization.

Impending paradoxical embolism is a biatrial thrombus in transit across a patent foramen ovale. It constitutes a rare clinical condition, possibly associated with multiple embolization and high mortality. We report the exceptional case of a 71-year-old-man presenting a giant impending paradoxical thrombus, complicated with pulmonary, cerebral, and coronary embolization. The patient underwent urgent surgery and was finally discharged without complications.

Dobutamine Stress Echocardiography Unmasks Early Left Ventricular Dysfunction in Asymptomatic Patients with Uncomplicated Type 2 Diabetes: A Comprehensive Two-Dimensional Speckle-Tracking Imaging Study.

BACKGROUND: Discrepancies are present in the literature on resting myocardial mechanics in patients with uncomplicated type 2 diabetes mellitus (T2DM). Data are noticeably sparse regarding circumferential function and torsional mechanics. Resting deformation imaging may not be sensitive enough to detect subtle dysfunctions. The aim of this study was thus to comprehensively evaluate myocardial mechanics in patients with T2DM at rest and to investigate whether dobutamine stress echocardiography could unmask functional alterations that would remain otherwise subtle at rest. METHODS: Forty-four patients with T2DM and 35 healthy control subjects of similar age and sex were prospectively recruited. After conventional echocardiography, myocardial mechanics was evaluated at rest and during low-dose dobutamine stress echocardiography (target heart rate, 110 beats/min). RESULTS: Patients with T2DM presented with altered global diastolic function but preserved systolic function. Deformation imaging indexes were similar between groups at rest, but significant differences were noticed under dobutamine infusion for longitudinal strain (-21.2 ± 2.4% vs -24.2 ± 2.5%, P < .001), circumferential strain (apex, -32.3 ± 5.3% vs -36.3 ± 5.3%, P = .002; papillary muscle, -25.6 ± 3.2% vs -28.0 ± 3.6%, P = .001; base, -23.2 ± 3.6% vs -25.3 ± 3.8%, P = .03), apical (11.2 ± 4.4° vs 14.1 ± 6.3°, P = .020) and basal (-12.2 ± 3.3° vs -14.3 ± 3.9°, P = .021) rotation, and twist (21.9 ± 5.9° vs 26.8 ± 8.3°, P = .007). Multivariate analysis identified epicardial fat, dyslipidemia, and fasting glycaemia as significant contributors to the changes from rest to dobutamine. CONCLUSIONS: These findings demonstrate the usefulness of dobutamine stress echocardiography in establishing impairments in myocardial mechanics in patients with uncomplicated T2DM. Systemic metabolic disturbances and epicardial fat act as the main contributors to the blunted response to dobutamine stress in these patients.

Delayed Formation of a Massive Atrial Hematoma After Coronary Intervention Manifesting With an Isolated Cough: Multimodality Imaging and Outcome.

Coronary artery perforation is a relatively rare but potentially life-threatening complication of percutaneous coronary intervention because it could result in cardiac tamponade; exceptionally, distal coronary perforation could cause an acute formation of a mural hematoma, which could also prove lethal without adequate management. We report an exceptional case of a 76-year-old man in whom an important left atrial hematoma formed progressively over weeks after a planned percutaneous coronary intervention and manifested with an isolated cough. Diagnosis was made using multimodality imaging. A conservative strategy was adopted and produced a favourable outcome.

[Methods of development of recommendations for clinical practice (RCP) and of setting-up of a platform cancer heart vessels (PTF-CHV) in the inter3C Vaucluse-Arles]. / Méthodes d'élaboration des recommandations pour la pratique clinique (RPC) et fonctionnement de la plate forme cœur vaisseaux cancer (PTF-CVC) dans l'inter3C Vaucluse pays d'Arles.

Monitoring and prevention of cardiovascular complications of anti-neoplastic treatment are currently well known for anthracyclines and trastuzumab but remain poorly implemented. The management of cardiac and vascular side effects of targeted therapies is not codified. The purpose of the platform heart-vessel cancer is to optimize the management of such complications within a small area (Vaucluse region of Arles). The platform will offer prescribers an easily accessible database, doctors performing exams standardized monitoring forms and patients a uniform follow-up. We report here the methodology of the elaboration of recommendations for clinical practice and the ways to develop the platform. After a year of active process, an analysis of the will be performed to see opportunities for improvement and dissemination on a larger scale.

Chronic calcific constrictive pericarditis complicating Churg-Strauss syndrome: first reported case.

Churg-Strauss syndrome is a necrotizing systemic vasculitis characterized by extravascular granulomas and eosinophilic infiltrates of small vessels. Although cardiac complications are considered to be relatively common, no case of constrictive calcified pericarditis has ever been previously described in this setting. In this report, we present the case of a 46-year-old man with Churg-Strauss syndrome, in whom we were able to document the development of symptomatic calcific constrictive pericarditis during a 10-year period despite long-term corticosteroid therapy.

ST elevation myocardial infarction with no structural lesions after a wasp sting.

BACKGROUND: Acute coronary syndromes after hymenoptera stings and other environmental exposures are referred to as the Kounis syndrome or allergic myocardial ischemia and infarction. CASE REPORT: We report the case of a 58-year-old man with transient inferior ST-segment elevation consistent with myocardial ischemia after a single wasp sting. Urgent cardiac catheterization revealed normal coronary arteries with a normal left ventriculogram. The evaluation and treatment of cardiac ischemia associated with an allergic reaction is discussed. CONCLUSION: ST elevation myocardial infarction after wasp envenomation is an exceptional and interesting pathology with a partially elucidated pathogenesis. The management of cardiac ischemia in this setting is uncertain.

Left ventricular systolic function deterioration during dobutamine stress echocardiography as an early manifestation of diabetic cardiomyopathy and reversal by optimized therapeutic approach.

Diabetes mellitus has been associated with changes in the structure and function of the myocardium manifesting in the early stages of the disease as subtle systolic and diastolic dysfunction; the role of dobutamine stress echocardiography (DSE) in this setting remains unclear. We sought to evaluate the prevalence of dobutamine-induced systolic dysfunction amongst diabetic patients with normal at rest left ventricular ejection fraction and no coronary artery disease and to investigate whether an optimized therapeutic approach can reverse these abnormalities. 1,363 patients with DM referred to our echocardiography laboratory for DSE between January 2008 and June 2010 were prospectively investigated. Patients with normal left ventricular ejection fraction (LVEF) at rest and significant deterioration during peak dobutamine infusion (defined as a ≥10% decrease) in the absence of coronary artery disease or vasospasm were enrolled. They received on top of their usual treatment 5 mg perindopril and had their glycemic control intensified. At 60 days, all of them were controlled for clinical status and underwent a control DSE. 18 patients were included, there were 9 males and 9 females, mean age was 66.1 ± 10.2 years. All the patients had type II DM with a mean duration of 12.7 ± 6.6 years. They all had normal at rest echocardiographic findings with no wall motion abnormalities; mean LVEF was 62 ± 6%. At peak dobutamine, LVEF significantly deteriorated in all the patients with a mean 15 ± 5% decrease compared to baseline. After therapeutic optimization, Glycated haemoglobin improved from 8.53 ± 2.05% to 6.8 ± 0.6% (δ HbA1C = 1.73%, P = 0.001), mean LVEF at peak dobutamine infusion evolved from 47.17 ± 4.2% pre-optimization to 58 ± 4.8% at control (10.83% improvement; P < 0.001). In patients with DM and normal at rest LVEF, Dobutamine infusion during DSE can induce a significant deterioration in LVEF in the absence of coronary artery disease or vasospasm. This specific condition could be largely reversed through an optimized therapy based on a tighter metabolic control and a more stringent renin-angiotensin-aldosterone system inhibition.

Left main coronary artery thrombosis complicating an idiopathic retroperitoneal fibrosis in a 37-year-old man with long-standing type I diabetes mellitus.

Retroperitoneal fibrosis is an uncommon collagen vascular disease of unknown etiology, characterized by the replacement of normal retroperitoneal tissue with fibrosis and/or chronic inflammation usually surrounding the abdominal aorta and the iliac arteries and extending into adjacent anatomic structures. No cases of acute coronary syndrome in the setting of retroperitoneal disorder have been published as yet. We report a 37-year-old man with a 14-year history of type I diabetes mellitus who was admitted to the endocrinology department for a routine check up and glycemic re-equilibration and who was later diagnosed to have an idiopathic retroperitoneal fibrosis. The patient presented during his hospitalisation with a non ST elevation myocardial infarction caused by an isolated thrombus located inside the left main coronary artery successfully treated with manual thrombectomy.

Impressive ST-segment elevation during dobutamine stress echocardiography in a patient with normal coronary arteries: dobutamine-induced vasospasm?

ST-segment elevation during dobutamine stress echocardiography is a serious complication usually related to severe coronary artery disease. However, it can occur in absence of significant coronary artery disease supposedly as a consequence of an occlusive dobutamine-induced coronary artery spasm. We report the case of a 56-year-old man without cardiovascular history who presented during a dobutamine stress echocardiography an intense precordial pain along with an impressive 10-mm ST elevation and in whom urgent catheterization documented the absence of significant coronary artery stenoses.

Coronary artery spasm and dobutamine stress echocardiography.

AIMS: The aim of this article was to assess whether abnormal dobutamine stress echocardiography (DSE) can be due to a dobutamine-induced coronary spasm in patients with angiographically documented vasospastic coronary arteries. METHODS AND RESULTS: Between January 2004 and April 2008, we prospectively evaluated all patients with known or suspected coronary artery disease (CAD) referred to the echocardiography laboratory for dobutamine stress tests (6061 examinations). Those with abnormal DSE underwent coronary angiogram with a systematic methylergometrine intracoronary injection in the case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients who had spontaneous occlusive coronary spasm or positive methylergometrine test, but no significant stenoses, were ultimately included in this study. About 581 patients had abnormal DSE, among them only 20 (3.4%) fulfilled the inclusion criteria. There were 15 males and 5 females, and mean age was 64.35 years (range 52-85); 8 patients had a known history of CAD and all of them had at least two established cardiovascular risk factors. The culprit vessel was the left anterior descending artery in 10 cases (50%), right coronary artery in 8 cases (40%), and left circumflex in 2 cases (10%). There was a systematic correspondence between the culprit arteries and dobutamine-induced wall motion abnormality territories. No complications occurred during examination or during the provocation test. All the patients were discharged with a calcium channel blocker and were doing well after 13 months of mean follow-up. CONCLUSION: Coronary artery spasm can be induced at DSE, but is a rare finding; it could, though, be clinically relevant as it may partly explain some erroneously labelled 'false-positive' examinations. Methylergometrine provocation test is a safe and advisable approach in such situations.