Denis Doyen

Transthoracic Echocardiography with Doppler Tissue Imaging predicts weaning failure from mechanical ventilation: evolution of the left ventricle relaxation rate during a spontaneous breathing trial is the key factor in weaning outcome.

IntroductionThere is growing evidence to suggest that transthoracic echocardiography (TTE) should be used to identify the cardiac origin of respiratory weaning failure. The aims of our study were: first, to evaluate the ability of transthoracic echocardiography, with mitral Doppler inflow E velocity to annular tissue Doppler Ea wave velocity (E/Ea) ratio measurement, to predict weaning failure from mechanical ventilation in patients, including those with atrial fibrillation; and second, to determine whether the depressed left ejection fraction and/or diastolic dysfunction participate in weaning outcome.MethodsThe sample included patients on mechanical ventilation for over 48 hours. A complete echocardiography was performed just before the spontaneous breathing trial (SBT) and 10 minutes after starting the SBT. Systolic dysfunction was defined by a left ventricle ejection fraction under 50% and relaxation impairment by a protodiastolic annulus mitral velocity Ea under or equal to 8 cm/second.ResultsA total of 68 patients were included. Twenty failed the weaning process and the other 48 patients succeeded. Before the SBT, the E/Ea ratio was higher in the failed group than in the successful group. The E/Ea measured during the SBT was also higher in the failed group. The cut-off value, obtained from receiver operating characteristics (ROC) curve analysis, to predict weaning failure gave an E/Ea ratio during the SBT of 14.5 with a sensitivity of 75% and a specificity of 95.8%. The left ventricular ejection fraction did not differ between the two groups whereas Ea was lower in the failed group. Ea increased during SBT in the successful group while no change occurred in the failed group.ConclusionsMeasurement of the E/Ea ratio with TTE could predict weaning failure. Diastolic dysfunction with relaxation impairment is strongly associated with weaning failure. Moreover, the impossibility of enhancing the left ventricle relaxation rate during the SBT seems to be the key factor of weaning failure. In contrast, the systolic dysfunction was not associated with weaning outcome.

Real time three-dimensional echocardiographic assessment of left ventricular function in heart failure patients: underestimation of left ventricular volume increases with the degree of dilatation.

Background: Accurate quantification of left ventricular (LV) volumes and ejection fraction (EF) is of critical importance. Cardiac magnetic resonance (CMR) is considered as the reference and three‐dimensional echocardiography (3DE) is an accurate method, but only few data are available in heart failure patients. We therefore sought to compare the accuracy of real time three‐dimensional echocardiography (RT3DE) and two‐dimensional echocardiography (2DE) for quantification of LV volumes and EF, relative to CMR imaging in an unselected population of heart failure patients. Methods and Results: We studied 24 patients (17 men, age 58 ± 15 years) with history of heart failure who underwent echocardiographic assessment of LV function (2DE, RT3DE) and CMR within a period of 24 hours. Mean LV end‐diastolic volume (LVEDV) was 208 ± 109 mL (121 ± 64 mL/m2) and mean LVEF was 31 ± 12.8%. 3DE data sets correlate well with CMR, particularly with respect to the EF (r: 0.8, 0.86, and 0.95; P < 0.0001 for LVEDV, LVESV, and EF, respectively) with small biases (–55 mL, –44 mL, 1.1%) and acceptable limits of agreement. RT3DE provides more accurate measurements of LVEF than 2DE (z= 2.1, P = 0.037) and lower variability. However, 3DE‐derived LV volumes are significantly underestimated in patients with severe LV dilatation. In patients with LVEDV below 120 mL/m2, RT3DE is more accurate for volumes and EF evaluation. Conclusion: Compared with CMR, RT3DE is accurate for evaluation of EF and feasible in all our heart failure patients, at the expense of a significant underestimation of LV volumes, particularly when LVEDV is above 120 mL/m2.

Tako-Tsubo cardiomyopathy presenting with cardiogenic shock successfully treated with milrinone: A case report

We report the case of a middle age patient presenting with Tako-Tsubo cardiomyopathy (TTC) complicated by cardiogenic shock that was successfully handled with milrinone. A 64-year old man presented with cardiogenic shock after benzodiazepine and alcohol intoxication. A slight elevation of troponin and typical left ventricular ballooning without coronary lesions suggested TTC. Within a few hours milrinone infusion normalized the cardiac index. TTC is responsible for severe transient left ventricular dysfunction occurring after physical or psychological stress. The major pathophysiological mechanism involved is disproportionate catecholamine secretion, which may stun the myocardium. We considered if treatment of this unique physiopathology with catecholamines could be dangerous in these patients and if alternative inotropes such as milrinone should be preferred.

Left main coronary artery compression associated with primary pulmonary hypertension.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 61-year-old man with known primary pulmonary arterial hypertension had typical angina when lying on his back. Strangely, in the left lateral decubitus position, the pain disappeared completely. Coronary 64-slice multidetector

Early detection of cardiac involvement in sarcoidosis with 2-dimensional speckle-tracking echocardiography.

BACKGROUND/OBJECTIVES Cardiac sarcoidosis (CS) is associated with high morbidity and sudden death. The absence of specific symptoms and lack of diagnostic gold standard technique is challenging. New imaging methods could improve the diagnosis of CS. The aim of our study was to assess the role of left ventricular (LV) longitudinal and circumferential strain as estimated by 2D speckle-tracking imaging in patients with diagnosed sarcoidosis without cardiac involvement according to the current guidelines. We investigated the prevalence of LV strain impairment in this population and assessed its relationship with clinical outcomes, composite of mortality, heart failure, arrhythmia and/or secondarily development of CS and cardiac device implantation. METHODS AND RESULTS We performed a prospective case-control longitudinal study including 35 patients with diagnosed sarcoidosis and normal cardiac function as assessed by standard transthoracic echocardiography and 35 healthy age- and gender-matched controls. All patients underwent a comprehensive echocardiographic study. Mean age of patients was 47.9±14.8years old (22 women). Compared with controls, global LV longitudinal strain (LV GLS) was reduced in sarcoidosis patients: (-17.2±3.1 vs -21.3±1.5%, p<0.0001). Circumferential LV strain was preserved in patients compared to controls (-19.9±-4.3% vs -21.3±1.5%, p=0.12). Impaired LV GLS was significantly associated with clinical outcomes (HR 1.56; [1.16-2.11], p<0.01) on univariate analysis. CONCLUSION Speckle-tracking echocardiography revealed decreased longitudinal LV strain in sarcoidosis patients that was associated with outcomes. LV GLS may represent an early marker of myocardial involvement in sarcoidosis patients that needs to be studied further.

Cardiac biomarkers in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) has recently been identified [1,2].TTC prevalence is up to 7% of all suspected acute coronary syndromes(ACS) in women, and 1% when both sexes are considered [3,4]. Re-hospitalizations are frequent and TTC mortality rate is higher than inthe general population [5]. Early phases of TTC mimic ACS anddistinguishing one from the other could betricky [6]. Cardiac biomarkersusewouldthereforebeinteresting.However,onlyfewbiologicaldataareavailable [7,8].WeaimedtoanalyzeB-typenatriureticpeptide(BNP)andtroponin I (TnI) in TTC patients.We conducted a multicentric prospective study between May 2009and October 2012. We recruited consecutive patients hospitalized forTTC and anterior ACS (age and gender matched) in 3 centers. ACS wasdiagnosed and treated in accordance with the European Society ofCardiology and American College of Cardiology Foundation/AmericanHeart Association criteria [9–11]. TTC was diagnosed using the MayoClinic criteria [6,12]. We conducted this study in compliance with theethical principles of the Declaration of Helsinki. Approval by the localethicscommittee wasobtained. Each patientgavehis written informedconsent.BNPlevelsweremeasuredonadmission.TnIdosagewasrealizedonadmission, then every 6 h for 24 h. Three patterns of TnI kinetic wereidentified: 1) peak (when TnI reaches a maximum before decreasing),2) decreasing (when TnI decreases continuously after the first assay)and 3) plateau (in the absence of clear peak). BNP/TnI ratio was calcu-lated using the TnI peak value. TnI measurements were performedwith the Beckman Access method, with a lowest detection limit of0.01ng/mlandapositivitythresholdof0.06ng/ml.BNPmeasurementswereperformedusinganimmunoassayBeckmanTriagemethod,withapositivity threshold of 100 pg/L. Glomerular filtration rate was evaluated(Modification of Diet in Renal Disease formula). Patients with severerenal failure were excluded ( b30 ml/mn).Ahighriskofbleedingwasde finedwithatleastoneofthefollowingcriteria: symptomatic bleeding, organic lesions likely to bleed,hemostatic abnormalities (platelet count b100,000/mm3, aPTT ratioN2,prothrombin time b40%),or thepresence of severe anemia (hemo-globin b8 g/dl) due to bleeding or unexplained.In this study, 62 TTC and 90 ACS patients (47 anterior ST-segmentelevation myocardial infarctions (STEMI) and 43 anterior non-ST-segment elevation myocardial infarctions (NSTEMI)) were recruitedover a 41-month period. The main features of our population are

A therapeutic challenge: catastrophic anti-phospholipid syndrome with diffuse alveolar haemorrhage

Diffuse alveolar haemorrhage (DAH) complicating primary catastrophic anti-phospholipid syndrome (CAPS) was diagnosed in a 50-year-old female patient. Treatment strategies are limited for this often life-threatening autoimmune disease that requires aggressive immunosuppression. In the absence of clinically validated treatment strategies, high-dose steroids associated with plasma exchange and eventually intravenous immunoglobulins were used to manage the disease. Its severity prompted the initiation of rituximab that was administered weekly for four consecutive weeks. Anticoagulation therapy, on the other hand, needed to be discontinued due to the major haemorrhagic episodes. This combination treatment provided an effective control of the CAPS-associated DAH and helped achieve clinical remission.

Endomyocardial fibrosis complicating primary hypereosinophilic syndrome

A 65-year-old woman was admitted for refractory acute pulmonary oedema requiring mechanical ventilation. Biological analysis showed hypereosinophilia (2300/ mm3), which was detected more than 6 months previously. Transthoracic echocardiography showed obliteration of the left ventricular cavity with material whose echodensity was distinct from that of myocardium (Fig. 1a, video 1). Left ventricular systolic function was preserved but diastolic function was impaired. Bedside contrast echocardiography confirmed material with contrast enhancement that was distinct from that of the myocardium. Absence of contrast in this material revealed areas of suspected thrombi (Fig. 1b, video 2). This technique was able to distinguish this material with hypertrophic cardiomyopathy whose contrast is not distinct from that of the myocardium. All these findings were suggestive of endomyocardial fibrosis (EMF) caused by hypereosinophilia. Cardiovascular magnetic resonance confirmed the presence of EMF associated with thrombi (Fig. 1c). Urgent surgical decortication was performed (Fig. 1d, video 3). The patient was weaned from mechanical ventilation and discharged from hospital. The pathology confirmed the presence of fibrosis with mural thrombi (Fig. 1e). A primary hypereosinophilic syndrome was suspected because of the absence of secondary cause of eosinophilia, of its persistence for more than 6 months, and of the involvement of at least one organ.

DIURETICS VERSUS FLUID LOADING IN ACUTE SUBMASSIVE PULMONARY EMBOLISM

Background: The benefit of volume expansion (VE) in submassive pulmonary embolism (PE) with right ventricular dysfunction (RVD) is unclear. We sought to compare the effects of a diuretic treatment versus fluid expansion in patients hospitalized for PE with RVD. Methods: We prospectively included 46

Symptomatic double aortic arch in an adult patient

Received 31 May 2016; revision accepted for publication 1 August 2016. A 28-year-old woman with a history of long-standing dysphagia (since the age of 10 years) was admitted to the emergency room with respiratory distress and marked stridor in the context of upper respiratory tract infection. Chest X-ray suggested right aortic arch and trans-thoracic echocardiography revealed normal intracardiac anatomy. Computed tomography (CT) scanning revealed a double aortic arch with a prominent right aortic arch constricting the oesophagus (the right subclavian and right common carotid arteries originated from the right aortic arch; the left common carotid and subclavian arteries originated from the left aortic arch) (figure 1). The patient underwent surgery (division and section of the compressive left aortic segment) and the immediate post-operative course was uneventful. However, despite initial satisfying evolution, dysphagia for solid food persisted and the patient was referred to our centre for further investigations. The CT scan revealed oesophageal strictures at the former site of compression (“footprint” of the vascular ring). Symptomatic double aortic arch in an adult patient