Risk factors for systemic emboli in infective endocarditis.

A retrospective study was undertaken to analyse the risk factors for systemic emboli in infective endocarditis. Patients (n = 80; 70% males; mean age 65 years; range 20-91 years) with infective endocarditis, as defined by the Duke criteria and diagnosed using transoesophageal echocardiography during the period January 1995 to March 2001, were included. The average time between the start of the illness and the beginning of antibiotic treatment was 55 days (range 0-405 days). The pathogens identified were streptococci (n = 47), staphylococci (n = 11), enterococci (n = 9), and others (n = 4). In nine cases, blood cultures were sterile. Thirty patients with at least one embolic episode were compared with 50 control patients. According to univariate analysis, the main risk factor for systemic emboli was the size of the vegetation (12.4 mm vs. 7.8 mm; p = 0.0005). The risk of emboli was 57% when the vegetation measured > 10 mm and only 22% when it was < 10 mm (p = 0.003). The mobility of the vegetation was also a risk factor: 48% if the vegetation was mobile; and 9% if fixed (p = 0.003). Sex, age, pathogen, antibiotic treatment, type of valve and the number and position of the vegetations were not found to be risk factors. With multivariate analysis, only mobility was identified as a risk factor. Overall, mobile vegetations > 10 mm in size were associated with an increased risk of embolic episodes in infective endocarditis.

[Two new cases of cardiac papillary fibroelastoma with ischemic stroke]. / Deux nouveaux cas de fibroélastome papillaire cardiaque responsable d'accident vasculaire ischémique.

A 22 and 25 year-old man were admitted to our emergency care unit for a stroke of the left superficial middle cerebral artery territory and vertebrobasilar infarction. Complete assessment of ischemic attack retained, in both cases, the presence of a valvular cardiac tumor. After heparin treatment, surgery confirmed the data provided by echocardiography. Histology confirmed the diagnosis of a papillary fibroelastoma. The diagnosis of cardiac tumors is based on transthoracic echocardiography and transesophageal echocardiography (TEE). High definition TEE allows localizing the tumor and determining its relationship with the contiguous anatomical structures. TEE is also a better guide for surgical procedure. Echocardiography is essential in the management of cerebral ischemic attacks in young patients.

[Myxoma of the left atrium with neurologic manifestations: 8 cases]. / Myxome de l'oreillette gauche à manifestations neurologiques: 8 cas.

A cohort of 8 patients with myxoma of the left atria and neurological manifestations is reported. Cerebral ischaemia, sometimes responsible for epileptic seizures, led to the discover of the myxoma (5 cases) or recurrence after exeresis (1 case) with imaging evidence of cerebral infarction in 5 cases. The first manifestation was a retinal embolism and temporary ischaemia in 1 case and pulmonary embolism with regressive cerebral ischaemia in another case with bilateral myxoma. Some clinical particularities should be underlined including exercise-induced neurological defect (3 cases), systemic embolism associated with cerebral infarction (3 cases), migraine headache as the initial manifestation (1 case) preceding by a pseudolupic syndrome suggesting the possibility of cerebral vasculitis or infectious endocarditis (1 case). The prognosis depends on the risk of recurrent atrial tumour formation (1 case). Metastases are rare. Multiple cerebral aneurysms (3 cases) did not lead to haemorrhagic complications.

[Paradoxical embolism of the aortic arch diagnosed by transesophageal echocardiography. Surgical treatment]. / Embolie paradoxale de la crosse aortique diagnostiquée par échocardiographie transoesophagienne. Traitement chirurgical.

The authors report the case of a woman who presented with a pulmonary embolism followed by systemic embolism. Transoesophageal echocardiography showed a persistent foramen ovale compatible with a possible paradoxical embolism. In addition, a mobile embolism in the aortic arch was demonstrated. This embolism was extracted under cardiopulmonary bypass to avoid a recurrence of embolism. Transoesophageal echocardiography is the only reliable, non-invasive method allowing simultaneous diagnosis of a right to left shunt and visualisation of the thoracic aorta.

[Aneurysms of the intra-atrial septum complicated by cerebral ischemia in young subjects. 4 cases]. / Anévrysmes du septum inter-auriculaire compliqués d'ischémie cérébrale chez le sujet jeune. 4 observations.

Transoesophageal echocardiography has improved the detection of potential sources of cerebral embolism. We report our experience with a group of 38 patients under 45 years of age who were examined after an arterial ischaemic cerebral event. We observed 4 patients (2 males, 2 females; age 17, 24, 38 and 40 years) with an atrial septal aneurysm. Cerebral ischaemia was permanent in 3 patients and temporary in 1 and a cerebral embolism was the most probable cause based on angiographic findings. The atrial septal aneurysm was only diagnosed by transoesophageal echocardiography (type IA in case 3, IB in the others). A patent foramen ovale was observed in 3 and this abnormality, which is known to have a high prevalence in the general population, could at most be an aggravating factor. In our series, we can assume a causal association between atrial septal aneurysm and stroke in young patients (10.5% among 38 young stroke patients vs 3% of 30 patients referred for other reasons). The treatment is still under discussion although the consensus would favour surgery if another heart malformation is associated, if a visible thrombus is identified or if repeated cerebrovascular events occur despite adequate anticoagulation. Studies conducted in large series of patients should provide more adequate therapeutic schemas.

[Traumatic rupture of the aorta diagnosed by transesophageal echocardiography. Apropos of a case and review of the literature]. / Rupture traumatique de l'isthme aortique diagnostiquée par l'échographie transoesophagienne. A propos d'une observation et revue de la littérature.

The authors report the case of subadventitial rupture of the isthmus of the aorta due to trauma, diagnosed by transoesophageal echocardiography. The role of transoesophageal echocardiography compared with conventional diagnostic techniques is discussed. This method of investigation is a very good diagnostic tool in cases of closed trauma of the thorax.

High levels of tumor necrosis factor-alpha and interleukin-6 in the ascitic fluid of cirrhotic patients with spontaneous bacterial peritonitis.

We prospectively measured the concentrations of immunoreactive tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), and interleukin-6 (IL-6) in the serum and ascitic fluid of 14 alcoholic cirrhotic patients with spontaneous bacterial peritonitis (SBP) and 16 alcoholic cirrhotic patients with sterile ascitic fluid. TNF-alpha levels in ascitic fluid were significantly higher for the patients with SBP: 399.57 +/- 129.23 pg/mL vs. 35.76 +/- 5.57 pg/mL (P < .001). IL-6 levels in ascitic fluid were also significantly higher for the patients with SBP: 170,713 +/- 57,109 ng/mL vs. 5,414 +/- 973 ng/mL (P < .001). By contrast, serum levels of TNF-alpha and IL-6 were just slightly more elevated than normal values. The concentration of IL-1 in the ascitic fluid of all patients was elevated, but there was no difference between patients with SBP or sterile ascites in this respect. In the patients with SBP, levels of TNF-alpha and IL-6 in ascitic fluid decreased during the first 48 hours of antibiotic treatment. Our results suggest that measurements of TNF-alpha and IL-6 in ascitic fluid may become useful markers both for the diagnosis of SBP and for monitoring the treatment of cirrhotic patients.

[Phlebitis following travel]. / Phlébite du transport. 16 observations.

The term of economy class syndrome has been used to describe the deep vein thrombosis which may follow air travel. The mechanisms suggested for this include tendency to clot formation in the legs secondary to the reduced venous return induced by the sitting position with direct compression of popliteal and femoral veins, and secondary to dehydration and haemo-concentration. However, these conditions are also observed with others means of transport. We describe 16 patients with deep vein thrombosis following travel by bus, car, truck and train. These 16 patients represent 3.4 percent of 465 patients with thromboembolism managed over a 52-month period in our department. All but one patients had one or more risk factors for deep vein thrombosis. The mean duration of the trip was 14.2 hours and the first symptom occurred less than a week after the journey in 75 percent of the patients. These first symptoms suggested deep vein thrombosis in 8, pulmonary embolism in 5, and deep vein thrombosis with pulmonary embolism in 3 patients. Regular non alcoholic drinks and regular walks seem to be sufficient to prevent deep vein thrombosis in the great majority of travellers. However, low dose heparin on a temporary basis or elastic stockings could be considered in high risk subjects.

[Localized type 2 dissection unrecognized by transesophageal echography. Apropos of a case]. / Dissections type 2 localisées méconnues par l'échographie transoesophagienne. A propos d'une observation.

The authors report a case of type 2 dissection, strictly confined to the terminal portion of the ascending aorta, not seen by transesophageal echocardiography because of the existence of a blind spot and responsible for a false negative. The role of TEE in the diagnostic approach to dissections is reviewed, as are its limitations, of which it is important to be aware because of the poor prognosis of pathology of this type.

[Current indications for inferior vena cava interruption]. / Indications actuelles des interruptions de la veine cave inférieure.

Clinical indications of vena cava interruption are reviewed. During the last few years pulmonary embolism frequency remained high and many new percutaneous vena caval filters became available. These facts probably explain the increasing use of these filters reaching about 10,000 filters each year in France. Existing data show that: embolic risk with antithrombotic agents is less than 5%, probably not far greater than embolic risk with cava filters (about 2%); complications encountered with the filters are caval thrombosis in 8%, and more or less than 4% other major complications; there is no controlled study comparing antithrombotic treatment associated with caval filters to antithrombotic treatment alone; there is no controlled study comparing new cava filters among them or to the Greenfield filter; economical implications of caval filters are mostly unknown. The only admitted indications of vena cava interruption, in case of proximal venous thrombosis, are contraindications to anticoagulation. In other situations no data allow to recommend a cava filter; indication will be discussed on a case by case basis. Prospective controlled studies are greatly encouraged.

Intravenous prostacyclin in thrombotic thrombocytopenic purpura: case report and review of the literature.

The use of prostacyclin infusion in thrombotic thrombocytopenic purpura is consistent with the hypothesis that patients may lack a plasma factor stimulating prostacyclin production. However, prostacyclin therapy, alone or in combination with aspirin, dipyridamole, steroid and plasmapheresis, failed in many cases. We here describe the case of a patient who responded dramatically to a combination of prostacyclin and plasma infusions, after conventional therapy had failed (plasmapheresis, fresh frozen plasma infusions). Prostacyclin was infused intravenously initially for 120 h from 4 to 9 ng kg min-1 and then continuously for 48 h at 9 ng kg min-1. Despite the scarcity of case reports in the literature, we conclude that the failure of prostacyclin in thrombotic thrombocytopenic purpura appears to be related to insufficient doses and/or duration of therapy.

Thrombotic thrombocytopenic purpura related to ticlopidine.

4 patients had typical features of thrombotic thrombocytopenic purpura (TTP) after 3 to 8 weeks of ticlopidine therapy. In 2 ticlopidine was the only medication taken before TTP; in another, rechallenge with drugs other than ticlopidine that the patient had been taking did not produce relapse. In all patients the delay between start of ticlopidine and TTP was in the same range as the latent period before ticlopidine-induced neutropenia. No relapse occurred in the 4 to 43 months of follow-up in the 3 surviving patients.

[Venous catheterization and congenital abnormalities of the superior vena cava]. / Cathétérisme veineux et anomalies congénitales de la veine cave supérieure.

Persistent left superior vena cava is encountered in about 0.3 to 0.4% of human beings. It derives from remnants of the left cardinal vein system. This results in either a duplication of the superior vena cava or in a single left vena cava. The diagnosis is easy in case of associated cardiovascular anomalies. Two cases of single left vena cava and one case of duplication of the superior vena cava are described. All were identified owing to repeatedly aberrant courses of central venous catheters. Diagnosis was easily provided by angiography. Clinical course was uneventful. Despite its usual good tolerance, the persistence of a left vena cava, as an isolated anomaly, must not be neglected as it carries many practical implications which are reviewed.

Disseminated intravascular coagulation in Fusobacterium necrophorum septicemia.

A previously healthy 42-year-old man developed, after a neglected tonsillitis, a severe Fusobacterium necrophorum septicemia with disseminated intravascular coagulation. Peripheral, painful, cyanotic and gangrenous lesions appeared on toes, external ears and nose tip. The patient survived. Consumption coagulopathy associated with tonsillitis should suggest F. necrophorum infection. Growth of these bacteria in blood cultures is slow and confirmation of the infection may thus be delayed.