S. Rekik

Native Valve Infective Endocarditis in a Tertiary Care Center in a Developing Country (Tunisia)

The aim of the study was to describe the epidemiological and clinical aspects of native valve infective endocarditis (IE) in a Tunisian high-volume tertiary care center and to identify the predictors of outcome. Demographic, clinical, laboratory, and echocardiographic characteristics were examined in 134 patients who fulfilled the modified Duke criteria for native valve IE between January 1997 and December 2006. Logistic regression analysis was used to identify prognostic factors for death. Mean age was 34.22 years. Diagnosis was definite in 93% of cases. Median time to diagnosis was 21 days. Rheumatic heart disease (RHD) was the predominant (45%) underlying heart condition. One or more vegetations were detected in more than 93% of cases. The median size of vegetation was >15 mm in 28% of cases. In 66 cases (49%), cultures remained negative. Serology was positive in 15 cases, and in 4 cases leaflet culture identified the agent. The infective agent was identified in 87 cases (65%), causative microorganisms were mainly Staphylococci (n = 30, including 6 coagulase-negative Staphylococcus), and Streptococci (n = 32). Overall mortality was 19%. On multivariate analysis, congestive heart failure (hazard ratio = 5.34, 95% confidence interval 1.67 to 17.15, p = 0.005) and large vegetations (>15 mm; hazard ratio = 5.78, 95% confidence interval 1.84 to 18.32, p = 0.002) were predictive of in-hospital mortality but not neurological complications or staphylococcus IE. In conclusion, IE remains a serious disease affecting a young population in Tunisia, with RHD as still the most common underlying heart disease, and it is associated with a high mortality.

Left main coronary thrombosis: unusual complication after radiofrequency ablation of left accessory atrioventricular pathway

Radiofrequency ablation (RFA) has established itself as a first-line therapy for the curative treatment of many patients with supraventricular or atrioventricular tachycardias and has exhibited a generally low incidence of serious sequelae (N Engl J Med. 1991;324:1612; Lancet. 1991;337:1557). Coronary artery injury is a rare complication. We present a patient with an acute thrombotic total occlusion of the left main coronary artery immediately after the end of RFA who was successfully treated with emergency percutaneous transluminal coronary angioplasty. This case illustrates an unusual coronary complication of RFA and serves as an exceptional example of survival with a good short-term prognosis after this unusual etiology of myocardial infarction.

Prosthetic valve endocarditis: management strategies and prognosis: A ten-year analysis in a tertiary care centre in Tunisia.

Background Prosthetic valve endocarditis (PVE) is a rare and serious complication after heart valve replacement; its optimal management strategy, though, still needs to be defined.Objective To study the clinical, microbiological and echocardiographic characteristics of PVE and to analyse the influence of the adopted therapeutic strategy (medical or surgical) on short- and midterm outcome in a tertiary care centre in a developing country (Tunisia).Methods All cases of PVE treated in our institution between 1997 and 2006 were retrospectively analysed according to the modified DUKE criteria.Results A total of 48 PVE episodes were diagnosed (30 men and 18 women), mean age was 37.93 years. Twenty-eight patients (58.33%) were exclusively medically treated, whereas 20 (41.66%) were treated by a combined surgical and medical strategy. Indications for surgery were haemodynamic deterioration in eight patients (40%), annular abscess in six (30%) and persisting sepsis in six (30%). In comparison with those from the medical group, operated patients had a longer delay to diagnosis (p=0.025), were more frequently in heart failure (p=0.04) and experienced more early complications (p=0.011); they also more frequently had prosthetic dehiscence (p=0.015), annular abscesses (p=0.039) and vegetations >10 mm (p=0.008). Conversely, no differences were found between the groups in terms of age, sex, or nature of involved organisms. In-hospital mortality for the medical group was 14.28% and for the surgical group 35% (p=0.09).Conclusion PVE is a very serious condition carrying high mortality rates regardless of the adopted strategy. Our study demonstrates that, in selected patients, medical treatment could be a successful and acceptable approach. (Neth Heart J 2009;17: 56-60.)

Unusual cause of syncope in a 17 year-old young woman: Left ventricular hydatid cyst

Cardiac involvement in echinococcosis remains a singular finding, possibly associated with confusing symptomatology. We report the original case of a 17 year-old young woman, referred to our cardiology department for repeated exertion syncopes, and ultimately, proven through echocardiography, serologies and magnetic resonance imaging to have a massive hydatid cyst developing inside the left ventricular cavity towards the outflow tract. The cyst has been surgically completely removed with excellent results.

Live Echocardiographic Visualization of the Migration of a Voluminous Left Ventricular Thrombus Complicating an Acute Myocarditis

A 52-year-old man was referred to our intensive care unit by the emergency department for chest pain and severe recent-onset dyspnea. The patient had no particular medical history and no cardiovascular risk factors. His complaints started 3 weeks previously after what he described as a severe flu with cough and fever. At clinical examination, the patient was breathless with a respiratory rate of 28 cycles per minute and a fever of 38.3°C. His heart rate was 88 bpm and blood pressure was 112/68 mm Hg. Pulmonary auscultation revealed bilateral wet rales in the lower lung fields. …

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.

Rapid Occurrence of Giant Left Ventricular Pseudoaneurysm after Mitral Valve Replacement

Left ventricular pseudoaneurysms are an uncommon and frightening complication after mitral valve replacement. We report the case of a 54‐year old woman, having undergone a mitral valve replacement with uneventful postoperative course and normal echocardiographic predischarge control, who was readmitted to hospital, only 16 days later, for rapidly progressing dyspnea, and finally echocardiographically diagnosed to have a massive 8‐cm long pseudoaneurysm communicating with the left ventricle through a narrow communication. The patient was proposed for emergency surgery but unfortunately died preoperatively.

Association entre tissue adipeux epicardique et dysfonction systolique infraclinique détectée par strain longitudinal chez les diabétiques mal équilibrés

OBJECTIVE The aim of this study is to assess the association between epicardial adipose tissue (EAT) and infraclinical myocardial dysfunction detected by strain imaging in diabetic patients (T2DM) with poor glycemic control. METHODS 22 patients with T2DM and 22 healthy control subjects of similar age and sex were prospectively recruited. Echocardiographic parameters were investigated. RESULTS In comparison to controls, diabetic patients had significantly higher body mass index (27.7 vs. 24.6; P<0.01), waist perimeter (103 vs. 84; P<0.001) and usCRP level (5.4 vs. 1.5; P<0.01). On echocardiography; no differences were found in terms of ejection fraction or ventricular mass; however, patients with T2DM had significantly thicker EAT (8.7±0.7 vs. 3.0±1.0; P<0.001) and altered systolic longitudinal strain (-18.8±3.2 vs. 22.3±1.6; P<0.001). On multivariate analysis, EAT was identified as an independent contributor (β=0,46, P=0.001) to systolic longitudinal strain. CONCLUSION In patients with T2DM and poor glycemic control; EAT was associated with infraclinical systolic dysfunction evaluated by global longitudinal strain despite normal at rest ejection fraction and no coronary artery disease.

Sténose tricuspide fonctionnelle sévère occasionnée par une importante végétation suite à une endocardite sur sonde de pacemaker

Lead-related infective endocarditis with negative hemocultures constitutes a severe condition potentially associated with a pejorative prognosis. It may induce a functional tricuspid stenosis caused by an important obstructive vegetation. We report the case of an 82 year-old woman in whom the lead-related endocarditis produced massive vegetation causing a severe functional tricuspid stenosis. We describe the medical history, diagnosis and treatment.

Forme atypique de cœur triatrial chez un patient de 59 ans

Cor triatrium is a rare congenital heart disease typically diagnosed amongst very young patients. Delayed diagnosis in the elderly is much more unusual. We report the case of a 59-year-old male with unremarkable medical history in whom we have discovered, on an echocardiography performed for an exploration of transient ischemic accident with atrial fibrillation, a particular form of an isolated cor triatrium dextrum investigated with multimodality imaging.