Maladies cardiovasculaires et diagnostic

Objective: Symptoms may be similar in patients with heart or lung disease. Thus, patients with lung disease are occasionally referred for evaluation by exercise echocardiography (ExE). We aimed to study the clinical, ExE data and outcome of patients with right ventricular (RV) dilation not explained by left ventricular (LV) heart disease.

Methods: Retrospective analysis of RV dysfunctional data in absence of LV heart disease in patients submitted to an ExE.

Results: Data on RV dilation in absence of LV heart disease were found in 21 of 18,400 ExE studies (0.11%). In 4 of the 21 patients (19%) RV function and systolic pulmonary artery pressure were normal at rest. However, exercise induced RV dysfunction and/or elevated systolic pulmonary artery pressure in all of these 4 patients. During follow-up of 5.2 ± 5.7 years 11 patients died (52%), most of them of respiratory causes (73%), being pulmonary thromboembolism (PTE) (38%) the most frequent final diagnosis.

Conclusion: RV dysfunction in absence of LV disease is rare among patients referred for ExE. ExE is of value as sometimes abnormalities on RV function arise only with exercise

A 61-year-old man with 5-fluorouracil (5-FU) chemotherapy suffered a cardiopulmonary arrest (CPA). The electrocardiogram showed changes consistent with myocardial infarction only during CPA that was normalized 30 minutes after cardiopulmonary resuscitation. Coronary angiography showed no significant stenosis. We suspected the cause of CPA to be vasospastic angina due to 5-FU and administered Benidipine, Diltiazem, and Isosorbide mononitrate to prevent recurrence of vasospasm.

Stress-induced cardiomyopathy (SICM) is characterized by transient systolic dysfunction of the apical and mid segments of the left ventricle without obstructive coronary artery disease. The precipitate causes are reported either an emotional or physically stressful event, which induces hyper-catecholamine secretion. It is extremely rare that SICM was induced by internal carotid artery (ICA) aneurysmal dilation. In this case report, we present an 86-year-old female patient with SICM induced by ICA aneurysm with panhypopituitarism, who on hormone replacement therapy had normalized asynergy.

Background: The initial systolic blood pressure (SBP) in patients presenting to the hospital with acute heart failure (AHF) informs prognosis, diagnosis, and guides initial treatment. However, over time AHF presentations with elevated SBP appear to have declined. The present study examined whether the frequency of AHF presentations with systolic hypertension (SBP >160 mmHg) declined over a nearly two-decade time interval.

Methods: This study compares four historical, cross-sectional cohorts with AHF who were admitted to tertiary care medical centres in the North-eastern USA in 1995, 2000, 2006, and 2011-13. The main outcome was the proportion of AHF patients presenting with an initial SBP >160 mmHg.

Results: 2,366 patients comprised the study sample. The average age was 77 years, 55% were female, 94% white, and 75% had prior heart failure. In 1995, 34% of AHF patients presented with an initial SBP >160 mmHg compared to 20% in 2011-2013 (p<0.01). Multivariate logistic regression demonstrated reduced odds of presenting with a SBP >160 mmHg in 2006 (0.64, 95% CI 0.42-0.96) and 2011-13 (0.46, 95% CI 0.28-0.74) compared with patients in 1995.

Conclusion: The proportion of patients with AHF and initial SBP >160 mmHg significantly declined over the study time period. There are several potential reasons for this observation and these findings highlight the need for ongoing surveillance of patients with AHF as changing clinical characteristics can impact early treatment decisions.

Background: Acute myocardial ischemia decreases electrical conduction velocity through the ischemic myocardium, the aim of the study is to evaluate the value of the change in QRS complex duration as a marker of reperfusion in patients presenting with ST segment elevation myocardial infarction.

Methods: The study included 100 patients presented with ST segment elevation myocardial infarction, 50% treated with fibrinolysis and 50% with primary Percutaneous intervention, all patients were subjected to 12 lead electrocardiography with measurement of QRS complex duration (in millisecond) on admission, sixty and ninety minutes post reperfusion , coronary angiography was done to all patients and they were divided into two groups according to myocardial blush grade, group A (5 5%) with normal reperfusion (grade 2 and 3) and group B (45%) with impaired reperfusion (grade 0 and 1).

Results: We found that the admission QRS duration didn’t differ in the two groups (p=0.859), and QRS complex duration was found to be significantly shorter in group A at both 60 and 90 min post reperfusion (p˂0.001 for both), and found a strong positive correlation between myocardial blush grade and QRS complex narrowing at both 60 min and 90 min post reperfusion respectively (r=0.731, p˂0.001 and r=0.739, p˂0.001). A cut off 10 msec was determined to be the best QRS complex narrowing duration for prediction of reperfusion at both 60 and 90 min post reperfusion with 100% sensitivity, and a specificity of (43.64% and 58.18%) at 60 min and 90 min post reperfusion respectively.

Conclusion: QRS duration changes post reperfusion is strongly correlated to myocardial reperfusion in patients presenting with ST segment elevation myocardial infarction.

Arterial compliance and stiffness of the ascending aorta are important components of the elastic nature of the arterial system. Several pathological conditions are known to potentially affect arterial compliance properties as occurs with the arterial hypertension, and diabetes mellitus. Factors known to affect LV elasticity are similar to those affecting aortic elasticity.

Our aim in that study is to study correlation of aortic stiffness and LV diastolic function and the factors that affect each. We scanned 254 patients presenting for routine echocardiography to Ain Shams University Hospitals Echocardiography unit; where clinical history was taken, examination and 2D echocardiography done where we indexed the elastic properties of the aorta by calculating of aortic distensibility (AD), aortic stiffness index (ASI), and pressure-strain elastic modulus (Ep), and LV diastolic function was evaluated as well.

Both presence and grade of left ventricular diastolic dysfunction were significantly correlated with each of arterial hypertension and diabetes mellitus separately and presence of both hypertension and diabetes mellitus was correlated with LVDD.

Aortic compliance-with its three studied elements; AS%, AD and ASI-was significantly correlated with grade of LVDD yet only elastic modulus was independently correlated with diastolic dysfunction.

Vascular closure devices following cardiac catheterization through the femoral artery have been gaining significant traction. Compared to the previous gold standard of manual compression, VCDs allow for shortened time to ambulation, decreased duration of hospitalization post procedure, and quicker hemostasis. Despite the advantages and variety of devices available, there are still complications to take into account. Our patient is a 74-year-old female who presented with intermittent right lower extremity pain. Her symptoms began two weeks prior to presentation, shortly after a recent left heart catheterization that was performed for chest pressure despite normal stress testing. A right lower extremity Doppler demonstrated decreased blood flow and a thrombus was presumed in the superficial femoral artery. After failed attempts of trying to retrieve the thrombus through a spider distal protection device and then a 7-French sheath, the patient was taken to the operating room. Specimens removed were identified as the Angio-Seal plug from the left heart catheterization. In conclusion, risk factors associated with VCD complications should be fully assessed due to the possibility of serious complications. In addition, misinterpretation can lead to delayed or incorrect treatment. Angio-Seal has proven to be highly efficacious, however, further studies will be needed to avoid device related complications.

Takotsubo cardiomyopathy (TCM) is a reversible disorder characterized by left ventricular wall apical ballooning precipitated by stressful event. Clinical presentation of this disorder mimics acute coronary syndrome (ACS). We are presenting a case of TCM, which is unique as rhabdomyolysis being the triggering factor. Although, our patient presented with features of NSTEMI on EKG and elevated troponins, diagnosis of TCM was made by echocardiography which showed left ventricular apical wall hypokinesis with Left ventriculogram showing the apical ballooning. The unique feature of the case was the triggering factor being rhabdomyolysis.

Background: The prosthetic heart valve thrombosis (PVT) is a life-threatening complication of mechanical valve prosthesis. It can be attributed more frequently to inadequate anticoagulant therapy. In the aortic and mitral position, reported incidences vary widely from 0.5% to 6% per patient-year, and are highest in the mitral position and up to 20% in tricuspid valve prosthesis. Medical therapy (Thrombolysis) has emerged as an alternative therapy in high-risk surgical patients, considering that surgical prosthetic valve replacement is related to significant operative morbidity and mortality rates. The purpose of this study is to present a single-center experience of 205 consecutive patients hospitalized between 2000 and 2016.

Methods: From 2000 to 2016, 205 consecutive patients were hospitalized in our center for mechanical prosthetic valve thrombosis (PVT). The diagnosis of PVT was mainly assessed by echocardiography and/or fluoroscopy. There were 41 men and 164 women aged between 07 to 75 years. Prosthetic valve location was mitral in 191 patients, tricuspid in 05, aortic in 8 and mitro-tricuspid in one case. Predisposing causes of MVT were: poor compliance with warfarin, pregnancy or unknown. The interval from first operation to valve thrombosis was from 1 day to 38 years. Delay from first symptoms to hospitalization ranged from 1 to 4 months.

The diagnosis was an incidental finding during an echocardiography, on the basis of a subacute increase in the transvalvular mean gradient seen due to thrombotic obstruction on transthoracic echocardiography and was confirmed by transesophageal echocardiography. First clinical symptoms were reported as systemic emboli, progressive exertional dyspnea (NYHA II to III–IV), muffled opening or closing sounds of the prosthetic valve, left heart failure, stroke, and cardiogenic shock. Transthoracic echocardiography is the diagnostic tool often used to evaluate a patient with valve prosthesis, when there is suspicion of PVT, and also is useful in the follow-up of patients during thrombolysis. Fluoroscopy was complementary. Anticoagulation regimen was inadequate, recently stopped or incorrectly conducted.

Results: There were two groups, the first group (A) comprised of 135 patients have been operated with cardiopulmonary bypass (CPB) (prosthetic replacement or declotting and excision of pannus). It is an emergency surgery in 101 patients. In this group, we deplore 18 (13.5%). 70 patients underwent medical treatment (heparin, oral anticoagulants and aspirin) on clinical, sonographic and under strict supervision in a hospital and some external purposes for a period of 07 days at 6 months. For the non-operated group, all patients have unlocked their prothesis; we deplored 05 deaths (7.14%) (hemorrhagic stroke, left and right ventricle dysfunction).

Conclusion: PVT remains a serious complication of mechanical heart valve prosthetic with high morbidity and mortality despite aggressive treatment by thrombolysis and/or surgery. Surgery treatment should be the preferred therapeutic modality for most patients with PVT.

Thrombolysis, followed by heparin, warfarin, and aspirin is advised for high-risk surgical candidates without hemodynamic instability under strict echocardiographic survey. Because of the high risk of thromboembolism during thrombolysis for left sided PVT.

For certain category of patients, medical therapy (thrombolysis anticoagulation++aspirin) may be offered in highrisk surgical patients, this with the consent of patients on medical and surgical rigorous monitoring and evaluating the operational risk compared to the risk of progression under medical treatment.

Bicuspid aortic valve is a common congenital defect associated with several other pathological processes. We describe a complex case in a 13-year-old boy where there was significant aortic valve insufficiency and a severely dilated ascending aorta. In addition, there was complex coarctation of the aorta in which both subclavian arteries arose from the coarctation site. A hybrid bilateral carotid-subclavian bypass grafting with coarctation stenting procedure was performed followed by a modified Bentall procedure. This case illustrates a successful two-stage, hybrid technique in a late-diagnosed paediatric patient.

Exercise test, hyperventilation test or cold pressor test was employed to reproduce ST elevation in patients with variant angina. However, cardiologists could not get the high positive frequency from these tests in patients without high disease activity. Now a days, cardiologists can easily perform coronary angiography or coronary computed tomography. Cardiologists skipped the non-invasive spasm provocation tests such as hyperventilation test or cold pressor test to diagnose patients with coronary artery spasm. Approximately a half patient with coronary spasm had pathologic responses of exercise tests. More than a third patient with coronary spasm and without fixed stenosis had ischemic findings on exercise tests, whereas more than two-third patients with coronary spasm and with organic stenosis had pathologic responses on exercise testing. We should reconsider the usefulness of exercise tests to obtain the ischemic findings due to coronary artery spasm in the clinic before performing the cardiac catheterization.