Guillaume Coutance

The prognostic value of markers of right ventricular dysfunction in pulmonary embolism: a meta-analysis

IntroductionIn pulmonary embolism (PE) without hemodynamic compromise, the prognostic value of right ventricular (RV) dysfunction as measured by echocardiography, computed tomography (CT) or biological (natriuretic peptides) markers has only been assessed in small studies.MethodsDatabases were searched using the combined medical subject headings for right ventricular dysfunction or right ventricular dilatation with the exploded term acute pulmonary embolism. This retrieved 8 echocardiographic marker based studies (n = 1249), three CT marker based studies (n = 503) and 7 natriuretic peptide based studies (n = 582). A meta-analysis of these data was performed with the primary endpoint of mortality within three months after pulmonary embolism, and a secondary endpoint of overall mortality and morbidity by pulmonary embolism.ResultsPatients with PE without hemodynamic compromise on admission and the presence of RV dysfunction determined by echocardiography and biological markers were associated with increased short-term mortality (odds ratio (OR) ECHO = 2.36; 95% confidence interval (CI): 1.3-43; OR BNP = 7.7; 95% CI: 2.9-20) while CT was not (ORCT = 1.54-95% CI: 0.7-3.4). However, corresponding pooled negative and positive likelihood ratios independent of death rates were unsatisfactory for clinical usefulness in risk stratification.ConclusionsThe presence of echocardiographic RV dysfunction or elevated natriuretic peptides is associated with short-term mortality in patients with pulmonary embolism without hemodynamic compromise. In contrast, the prognostic value of RV dilation on CT has yet to be validated in this population. As indicated both by positive and negative likelihood ratios the current prognostic value in clinical practice remains very limited.

Prognostic value of brain natriuretic peptide in acute pulmonary embolism

IntroductionThe relationship between brain natriuretic peptide (BNP) increase in acute pulmonary embolism (PE) and the increase in mortality and morbidity has frequently been suggested in small studies but its global prognostic performance remains largely undefined. We performed a systematic review and meta-analysis of data to examine the prognostic value of elevated BNP for short-term all-cause mortality and serious adverse events.MethodsThe authors reviewed PubMed, BioMed Central, and the Cochrane database and conducted a manual review of article bibliographies. Using a prespecified search strategy, we included a study if it used BNP or N-terminal pro-BNP biomarkers as a diagnostic test in patients with documented PE and if it reported death, the primary endpoint of the meta-analysis, in relation to BNP testing. Studies were excluded if they were performed in patients without certitude of PE or in a subset of patients with cardiogenic shock. Twelve relevant studies involving a total of 868 patients with acute PE at baseline were included in the meta-analysis using a random-effects model.ResultsElevated BNP levels were significantly associated with short-term all-cause mortality (odds ratio [OR] 6.57, 95% confidence interval [CI] 3.11 to 13.91), with death resulting from PE (OR 6.10, 95% CI 2.58 to 14.25), and with serious adverse events (OR 7.47, 95% CI 4.20 to 13.15). The corresponding positive and negative predictive values for death were 14% (95% CI 11% to 18%) and 99% (95% CI 97% to 100%), respectively.ConclusionThis meta-analysis indicates that, while elevated BNP levels can help to identify patients with acute PE at high risk of death and adverse outcome events, the high negative predictive value of normal BNP levels is certainly more useful for clinicians to select patients with a likely uneventful follow-up.

Capnocytophaga canimorsus endocarditis with root abscess in a patient with a bicuspid aortic valve

Infective endocarditis caused by a zoonotic micro-organism is a rare clinical condition. Capnocytophaga canimorsus is a bacterium of the normal oral flora of dogs and cats. It can be transmitted to humans by bite, scratch or others close contacts with dogs, and occasionally cats. It has been implicated in a spectrum of disorders including septicemia, meningitis and septic arthritis. Splenectomy and alcoholism have been reported to be risk factors, but infection may occur in previously healthy patients. We reported the case of a 65-year-old man with bicuspid aortic valve endocarditis and multiple abscesses of the aortic wall caused by the canine bacteria Capnocytophaga canimorsus. This case highlights the capacity of Capnocytophaga canimorsus to produce endocarditis whose incidence may be underestimated due to slow growth and incorrect identification of the organism.

Hypoplasia of the aorta in a patient diagnosed with LMNA gene mutation.

Hypoplasia of the aorta is a rare entity comprising tubular hypotrophy of a large segment of the thoracic and the abdominal aorta. We report for the first time the case of a 26-year-old man with Emery-Dreifuss muscular dystrophy presenting severe and diffuse hypoplasia of the aorta.

Pulmonary embolism, aortic root aneurysm and floating left heart thrombus.

MOTS CLÉS Embolie pulmonaire ; Embolie paradoxale ; An 87-year-old woman was referred to our institution after reporting syncope. Examination revealed tachycardia (140 beats per minute), cold extremities and clinical signs of elevated jugular venous pressure; her blood pressure was 60/50 mmHg and blood oxygen saturation was 80%. Electrocardiogram showed S1 Q3 and right bundle branch block patterns. Transthoracic echocardiogram revealed a dilated and hypokinetic right ventricle (estimated systolic pulmonary artery pressure 65 mmHg) and an aortic root aneurysm (sinuses of Valsalva: 70 mm). A large serpentine thrombus was trapped in the mitral valve (Fig. 1). Contrast-enhanced computed tomography showed bilateral pulmonary embolism associated with aneurysm of the ascending aorta (Fig. 2). Neither surgical embolectomy nor thrombolytic therapy was performed due to the patient’s poor general condition. Medical treatment with saline fluid loading, intravenous unfractionated heparin and oxygen ther-