Biomedical subjects
Publications and source records attributed to J L Vandenbossche.
We report the observations of three patients with myocarditis. The first one with chest pain, the second one with a pseudo-infarct presentation and the third one with a cardiogenic shock. We discuss the different anatomo-clinical presentations of myocarditis, the diagnosis, the indications of endomyocardial biopsies and the prognosis of this pathology.
BACKGROUND: Cardiac involvement in children with human immunodeficiency virus (HIV) infection is a well-known entity and occurs clinically more often in patients with advanced acquired immunodeficiency syndrome (AIDS). Autonomic dysfunction is less known, especially in children. HYPOTHESIS: The aim of this study was to asses the prevalence of cardiovascular abnormalities in a pediatric population with HIV. We also aimed to evaluate whether autonomic involvement occurs in the same population and is dependent on echocardiographic abnormalities. METHODS: The occurrence of echocardiographic abnormalities was evaluated in 22 children with HIV infection, and five noninvasive tests were performed to evaluate the presence of autonomic dysfunction. RESULTS: We found cardiac lesions in four children (18%), consisting of pericardial effusion in three children, wall motion abnormalities in three children, and acute aortic endocarditis in one child. All cardiac abnormalities were found at Stage C by Center for Disease Control (CDC) revised classification. We also found left ventricular filling pattern abnormalities consisting of E-wave maximal velocity decrease and prolonged deceleration time compatible with diastolic dysfunction. One of the five autonomic tests (Valsalva maneuver) was significantly altered, even in patients without abnormal echocardiography, suggesting mild autonomic dysfunction. CONCLUSION: The study demonstrated a high prevalence of cardiac lesions in children with HIV infection and indicated the presence of autonomic dysfunction even when there are no echocardiographically detected abnormalities.
The assessment of the thrombo-embolic risk is currently well defined in case of atrial fibrillation, in the general population as well as in several subgroups. Predictive factors of thrombo-embolism have been identified, they are clinical and echocardiographic criteria. They allow to stratify the individual risk of each patient and to establish the therapeutic attitude best suited to its thrombo-embolic and haemorrhagic risk profile. Recent clinical trials have demonstrated that oral anticoagulation with coumarinics, adjusted at an INR between 2 and 3, provided a greater protection for patients at higher risk, compared to aspirin, with an acceptable low rate of haemorrhagic complications. When atrial fibrillation is of recent onset, the therapeutic attitude will take into account the time delay between onset of the arrhythmia and the medical consultation, 48 h representing the maximal delay allowed to perform cardioversion without prolonged anticoagulation.
We report cardiac valvulopathy occurring after prolonged intake of anorectic drugs containing fenfluramine (Fen) and/or dexfenfluramine (D-Fen) in 14 patients whose evolution was followed by Doppler echocardiography. A relation between these drugs and valvular regurgitation was first suspected after 4 cases reported in 1991-1992 and confirmed after 3 more patients in 1993-94-95, who were taken D-Fen or Fen alone. All were women, aged 42 to 73 years. Patient 1 to 7 had been taking Fen and/or D-Fen for 14 to 52 months. Patients 8 to 14 had been taking a mixture of Fen and/or D-Fen, diethylpropion and chinese-herbs for 3 to 69 months. These last 7 patients developed renal failure requiring hemodialysis or peritoneal dialysis in 5 and subsequent renal transplantation in 4. All presented with cardiac murmur(s) and some with dyspnea or palpitations. An initial echocardiography was performed at the time of diagnosis, and was repeated annually for a follow-up period extending to 8 years. We conclude that a relation between Fen and/or D-Fen and the outbreak of valvular heart disease is identified in our patients, confirming previous findings. The nephrotoxicity observed in 7 patients is due to the "chinese-herbs". When Fen and/or D-Fen are stopped and proper therapy initiated, the cardiac symptoms may stabilize or even subside, though slowly. Hemodynamic unstability and/or infection appear to be an aggravating factor. These patient's follow up must be prolonged for several years and is readily achieved with echocardiography. Systematic screening of all patients having taken Fen and/or D-Fen must be performed, as renal and urinary screening for all patients having taken chinese-herbs. Endocardial prophylaxis must always be prescribed.
BACKGROUND: Recently, the automated cardiac output method (ACM) was introduced for the calculation of blood flow at the left ventricular outflow tract (LVOT). This study was performed to examine the possibility of using ACM for flow calculation at the level of the mitral valve and for the quantification of mitral regurgitation (MR) in vitro and in vivo. METHODS AND RESULTS: In a computer-controlled in vitro model of the human heart, aortic and mitral normal bioprosthetic valves were inserted. ACM and electromagnetic probe flow measurements correlated well at the LVOT and at the mitral level (r2 = 0.79 and 0.77, respectively). For stroke volumes ranging from 30 to 100 ml/beat, there was no statistically significant bias between ACM and electromagnetic flow probe (-1.5 and 1.3 ml for LVOT and mitral level, respectively). Limits of agreement were [-14; +11] ml and [-18; +16] ml, respectively. We evaluated 68 patients in our in vivo study. They were divided into three groups according to the results of "standard" echocardiographic Doppler methods for the semiquantification of MR: echocardiographic color Doppler cartography, intensity of the continuous wave Doppler spectra, and in some patients, pulmonary venous flow, conventional Doppler, and proximal isovelocity surface area quantitative data. Group 1 consisted of 35 patients without MR or a physiologic one; the 17 patients in group 2 had a mild MR (1-2/4) and in group 3, 16 patients with MR 3-4/4 were included. Regurgitant volume (RV) was calculated as the difference between ACM mitral flow and ACM aortic flow, and regurgitant fraction (RF) was defined as the ratio between RV and ACM mitral flow. When mitral flow was measured only from the four-chamber view, we found in group 1, RV = -0.57 (0.67) L/min and RF = -16% (19%); in group 2, RV = -0.31 (1.06) L/min and RF = -8% (19%); and in group 3, RV = 1.53 (0.94) L/min and RF = 23% (13%). RV and RF were statistically higher in group 3 compared with group 2 or group 1 (p < 0.0005), but no significant difference was found between groups 1 and 2. When mitral flow was measured by the mean value of ACM four-chamber and two-chamber views, this resulted in group 1, RV = -0.26 (0.63) L/min and RF = -8% (15%); in group 2, RV = 0.01 (1.04) L/min and RF = -2% (18%); and in group 3, RV = 2.07 (1.21) L/min and RF = 34% (19%). RV and RF were again significantly higher in group 3 (p < 0.0001). There was no significant difference between group 1 and group 2, but in group 1 RF was no longer statistically different from 0%. CONCLUSIONS: (1) In our in vitro setting, ACM is reliable both at the LVOT and at the mitral valve. (2) In the in vivo situation, some overlapping does exist between the three groups of MR. However, ACM is a very easy, rapid, and objective method to differentiate hemodynamic nonsignificant (<3/4) from significant (> or =3/4) MR. Together with other well-known methods for the quantification of MR, it should facilitate the gradation of MR in the clinical setting. The absence of significant differences between group 1 and group 2 proves that the accuracy of ACM measurements at the mitral valve needs to be ameliorated before ACM can be used as a gold standard for the noninvasive measurement of RV and RF.
Despite Beta-blockade therapy has been considered as an absolute contraindication in the treatment of heart failure, it has been shown that they could have a beneficial effect, provided that they were introduced at very low dose, and very progressively in addition of the traditional treatment. The advances in the understanding of the neuro-hormonal mechanisms of heart failure have modified the therapeutic strategy: the deleterious effect of the activation of the sympathetic nervous system on the myocardium has served as the rationale for randomized clinical trials comparing beta-blockade to placebo: the current data are promising, suggesting a beneficial effect on survival as well as on quality of life. However, these results have to be confirmed by larger trials, currently underway, before to consider that beta-blockade should definitely be incorporated in the treatment of heart failure.
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Endocarditis at the aortic level is usually characterized by the presence of a vegetation or an abscess on echocardiography. This paper reports on what is believed by the authors to be the first case of endocarditis presenting as an aneurysmal deformation of one aortic cusp without a vegetation.
The Doppler indexes of tricuspid porcine bioprosthetic valves were evaluated in twelve patients without clinical and two-dimensional echocardiographic evidence of valve dysfunction. Peak and mean pressure gradients across the prostheses were measured using the simplified Bernoulli equation. All the Doppler measurements were compared during inspiration and expiration. During inspiration peak velocity, peak gradient and mean gradient (1.52 +/- 0.28 m/s; 9.7 +/- 3.05 mmHg; 4.07 +/- 1.16 mmHg) were significantly higher than during expiration (1.28 +/- 0.8 m/s; 6.58 +/- 2.7 mmHg; 2.98 +/- 1.13 mmHg; p < 0.01) but pressure half time was not significantly different (122 +/- 62 ms versus 134 +/- 75 ms; p > 0.05). Inspiratory range of peak velocities, peak gradients, mean gradients and pressure half times were respectively 0.8-2.04 m/s; 4.9-16.6 mmHg; 1.2-7.2 mmHg; 42-340 ms while expiratory range of values was 0.8-1.93 m/s; 2.6-15 mmHg; 1.1-5.7 mmHg; 46-345 ms. These data suggest that even very long pressure half times do not indicate valve dysfunction. This study demonstrates that large variation of Doppler parameters are present during respiration and could produce inaccuracy in the assessment of bioprostheses in tricuspid position if they are not taken in consideration.
A 17-year-old boy presented with fever, bilateral conjunctival infection, angina and extensive cervical adenopathy. Amoxycillin was started. Ten days later he was admitted to hospital because of persistent high fever, cervical adenopathy, erythema of the pharynx and tongue and lip fissuration. The most important interventions of his first hospitalization were endotracheal intubation because of increasing dyspnoea due to adult respiratory distress syndrome and haemodialysis for renal insufficiency. His admission to our hospital was marked by the echocardiographic discovery of giant coronary aneurysms in the first few centimeters of both right and left coronary arteries. Coronary angiography confirmed giant aneurysm formation of the right and left coronary arteries. Similarly, medium sized arteries (cerebral, hepatic, mesenteric, iliac) presented abnormalities and laboratory findings. This is the first description of adult-onset Kawasaki disease with giant coronary aneurysm formation and more generalized arterial involvement. The severity of the clinical symptoms and the severity of the coronary disease indicates that Kawasaki disease of the adult does not always have a benign course.
A 72 year old man was admitted with severe dyspnoea. Ten days before he had had intense thoracic pain with loss of consciousness that was followed by increased dyspnoea. A continuous murmur was heard in the precordial and the left infrascapular regions. Lung auscultation showed stasis over the lower half of both lungs. Transthoracic echocardiography showed a bicuspid aortic valve and a dissection of the proximal aorta, which was considerably enlarged. Transoesophageal echocardiography confirmed dissection of the proximal aorta and showed a communication from the false lumen of the aortic dissection to the left atrium; and colour flow Doppler showed a continuous shunt to the left atrium. After transoesophageal echocardiography the patient had emergency surgical repair, which was successful. He had no complications in the post-operative period.
OBJECTIVE: To elucidate why different types of contrast appear in the left atrium during transoesophageal echocardiographic contrast studies. This should lead to a more uniform definition of true patent foramen ovale. BACKGROUND: The Valsalva manoeuvre and cough are routinely used to enhance right to left shunt for the detection of patent foramen ovale. No information is, however, available on the effect of these manoeuvres on the intrinsic echogenicity of blood in the left atrium. METHODS: 30 consecutive patients referred for transoesophageal echocardiography were studied. Gain settings were relatively high so that no details were lost. The appearance of contrast during normal respiration, cough, and the Valsalva manoeuvre was looked for in the left atrium with and without venous injection of 10 ml of 5% dextrose. Frequency of contrast appearance in the left atrium was expressed as a percentage. Intensity of contrast, when present, was graded 1 (mild), 2 (moderate), or 3 (equal to right atrial contrast during injection). Timing was assessed in cardiac cycles after the end of respiratory manoeuvres. RESULTS: Left atrial contrast appeared as a "snowstorm" flowing from the right pulmonary veins towards the middle of the left atrium. It was present respectively with and without contrast injection in eight and five patients during normal respiration, in 15 and seven during a cough, and in 20 and 14 during the Valsalva manoeuvre. When present, the mean intensity of contrast was 1.0 during normal respiration, 1.4 during a cough, and 1.4 during the Valsalva manoeuvre. The mean delay of contrast appearance was 3-4 cycles after release of the Valsalva manoeuvre and after onset of cough. CONCLUSIONS: Respiratory manoeuvres frequently induce the transient appearance of mild to moderate contrast in the left atrium, most often independently of venous injections. Mild contrast was seen only with high gain settings. This contrast is likely to be related to transient stasis in the pulmonary circulation. In some cases peripheral venous injections of dextrose solution produced, without any respiratory manoeuvre, a similar contrast after the first four cardiac cycles of the right atrium filling, which is likely to represent recirculation of the injected bolus through the pulmonary capillary bed. Therefore respiratory manoeuvres should always be performed before contrast injections to allow better distinction between this background and true patent foramen ovale or pulmonary arteriovenous fistula.
Antemortem diagnosis of cardiac metastases of a hepatocellular carcinoma is rarely observed. In a 52-year-old female patient with a history of posthepatitic cirrhosis and partial hepatectomy, transthoracic echocardiography brought to light a mass in the right atrium. After location and characterization of the tumor by transesophageal echocardiography, a transvenous biopsy confirmed the diagnosis of metastasis of a hepatocellular carcinoma.
To better elucidate the possible role of the patent foramen ovale (PFO) in patients with unexplained stroke, the relation between the incidence of stroke and 3 characteristics of PFO (timing, magnitude of appearance of echocardiographic contrast in the left atrium, and morphology of the atrial septum) was analyzed. Twenty-nine patients with unexplained stroke and 28 without stroke were compared. A significant relation was only found between the incidence of cerebrovascular accident and positive contrast echocardiography in patients with early and massive passage of contrast in the left atrium (6 of 29 [21%] in the stroke group vs 0 of 28 [0%] in the control group; p < 0.05). An abnormal morphology of the foramen ovale was found more frequently in patients with PFO than in those without PFO (9 of 13 [69%] vs 1 of 44 [2%]; p < 0.001). The results suggest the use of timing and quantification of contrast appearance in the left atrium during contrast transesophageal echocardiography, and that paradoxical embolism through a PFO is a possible mechanism of cryptogenic stroke only if there is a massive passage of contrast through an abnormal foramen ovale.
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Transoesophageal echocardiography identified a pacemaker lead infection in a patient in whom transthoracic echocardiography was negative and there were no specific signs of skin inflammation over the pulse generator.
A 38-year-old man with a Starr-Edwards mitral prosthetic valve presented with a Staphylococcus aureus septicemia. Twenty-four hours later, transthoracic echocardiography did not show obvious vegetations but Doppler examination of the prosthetic valve demonstrated a prolonged half pressure time and an elevated peak transmitral velocity. Seventy-two hours after the first septic event transesophageal echocardiography revealed a large annular pannus floating in the left atrium in systole and protruding in the prosthetic cage during diastole. This case report emphasizes the importance of transesophageal echocardiography in septic patients with prosthetic valves and underlines the possibility of extremely rapid pannus formation in these patients.