Transthoracic Echography Research Articles

Ischemic stroke in a young patient: role of a bubble test

A 29-year-old female patient, with a known history of erythematosus disseminated lupus, consulted for a left hemiplegia with aphasia and central facial paralysis, the cerebral CT scan showed an ischemic stroke in the territory of the superficial right sylvian artery. The neurologist asked as part of the etiological assessment for an echography of the supra-aortic trunks which appeared normal as well as a trans-thoracic echography which appeared initially without anomalies. By taking into consideration the young age of the patient and his history of systemic disease, we mentioned a permeable oval foramen (FOP), then we completed the assessment with a bubble test with concomitant transthoracic echocardiography which revealed a passage of more than 30 bubbles through the FOP (A) after valsalva maneuver. FOP is present in 25% of individuals. Most of the time, patients with this anomaly are asymptomatic. Nevertheless, it is important to mention its presence in front of any signs of arterial ischemia such as a stroke attesting to a paradoxical embolism. Its pathophysiology is based on a persistent, intracardiac right-left shunt with the migration of a thrombus from the right cavities to the left heart through the FOP. The Management is based either on a drug treatment, or on the closure of the intracardiac shunt within a synthetic prosthesis, by surgery or percutaneously.

Safety and efficacy of day case PFO closure using transthoracic echography and fluoroscopic guidance. Comparison between Occlutech and Amplatzer devices

The purpose of this work is to report one-year experience in day case transcatheter closure of PFO using different occluders. A comparison study is also performed between the Figulla Flex II and PFO Amplatzer devices. From January to December 2018, 106 patients suffering from a stroke underwent transcatheter PFO closure as day-case procedure. Devices employed included: Figulla Flex II (Occlutech, n = 66), PFO AmplatzerTM (AGA, Saint Jude medical) ( n = 36), CeraFlex PFO Occluder (Lifetech scientific, n = 2) and Nit-occlude PFO (PFM medical, n = 2). Procedure was performed under local anaesthesia with fluoroscopic and transthoracic echocardiographic (TTE) guidance. Implantation succeeded in all. The complications included transient ST deviation in 10 patients due to air embolism with no permanent damage. In 2 cases, the hospital discharge was delayed: one because femoral fistula requiring compression (day 5) and the other because of pericardial effusion requiring no drainage (day 2). At the one-month control, 5 patients complained of chest tightness, 8 reported palpitations, 5 had AF. Eighty-eight patients had no shunt on contrast TTE, 17 had a persistent shunt, and 1 was lost on follow-up. At the 6-month control, 8 of these 17 patients had no persistent shunt. In the comparative study between Occlutech and Amplatzer devices, patient were older in-group Amplatzer but had a similar weight. No significant difference could be observed between the 2 groups concerning time of fluoroscopy, dose of radiation, ST deviation, and persistence of shunt at one month ( P = NS). No recurrence of stroke was noticed during follow-up (127 ± 98 days). Transcatheter PFO closure as a day case procedure is safe and effective. This approach is not more risky for the patients in terms of embolisation and final results. No significant difference could be observed between the Occlutech and Amplatzer PFO devices.

P633 Murmuring the diagnosis

Abstract INTRODUCTION Coronary-cameral fistulas (CCF) are mostly congenital, rarely acquired malformations that create a communication between one or more coronary arteries and one of the cardiac chambers resulting in arterio-venous or arterio-arterial connections, giving rise to left-right or left-left shunts. CASE REPORT A 64 year-old man with history of heart transplant in September 2018 for severe post-ischemic heart failure, was transferred in our cardiology service after a three months cardiac reeducation program. The patient was to be discharged on the same day but the accidental discovery of a myocardial septo-apical infarction with ST segment elevation motivated his admission for urgent coronary angiography. The patient did not present any thoracic pain, only a slight numbness in his right shoulder. Troponin T value was 1735pg/ml. The coronary angiography showed a recent occlusion in the distal segment of the left anterior descending artery presenting with an aneurismal dilatation and CCF. Further we completed the exam with a transthoracic echocardiography showing an akinetic apex in the presence of a fistula between the left anterior descending artery and the apex of the right ventricle with a high velocity flowing (Vmax = 1.8m/s) preferentially directional to the right ventricle. Reviewing the medical history we found out that the patient had had a endomyocardial biopsy three days before this episode. Clinically a continuous cardiac murmur could be heard and the patient presented NYHA II dyspnea. Following this clinical presentation we decided to discuss the case within a heart team reunion and the decision taken was to place a covered stent in the distal segment of the left descending artery so as to permit the occlusion of the fistula. The evolution was favorable and the patient was discharged five days later. DISCUSSION Diagnosis of acquired CCF is suspected by clinical history and recurrence of symptoms, occurrence of a new continuous machinery cardiac murmur and a palpable thrill. Normally conservative medical management is sufficient to relieve symptoms in these acquired fistulas and spontaneous resolution is very common in CCF acquired following endomyocardial biopsy. In our case report we noted the occurrence of a systolo-diastolic murmur following endomyocardial biopsy with a patient who was symptomatic of myocardial infraction. The literature describes report cases of symptomatic patients who needed a surgical or endovascular occlusion of the acquired CCF following endomyocardial biopsy by implanting a covered stent or with a covered balloon. CONCLUSION The termination site of acquired iatrogenic CCF following endomyocardial biopsy in the heart transplant population is usually the right ventricle with an elevated ratio of spontaneous resolution of this coronary-cameral communications. However in sysmptomatic patients a surgical or endo-vascular occlusion may be needed. Abstract P633 Figure. Transthoracic echography findings

Left Atrium Myxoma Revealed by an Ischemic Stroke: About a Case

Introduction: Left atrial myxoma is a rare benign tumor. It can be an embolic complication such as an ischemic stroke. Case presentation: It was a 48 years old patient who was referred to our unity for the etiological investigation of an ischemic stroke. She did not have personal medical and surgical history. She had a recent right hemiplegia. The cardiac auscultation found a mitral diastolic murmur. The brain CT showed a recent ischemic stroke in the superficial and deep left sylvian territory. The transthoracic echography revealed a myxomatous mass, responsible of an obstacle of the left ventricular filling. Anticoagulation by antivitamin K (AVK) had been initiated and a resection of the mass indicated. Conclusions: The left atrial myxoma is a rare benign tumor whose mode of revelation can be an embolic complication. The Echocardiography is reference imaging modality in diagnosis with a high sensitivity.

Protocolo ultrasonográfico enfocado en cirugía cardiaca posquirúrgica CCROSS (Cardiac, Cerebral, Renal, Optic nerve, lung ultraSound Study).

The use of echocardiography is very useful in the evaluation, treatment and follow-up of the patient in critical condition. Along with clinic and the stethoscope, it is a tool that complements the act of the physician faced with the diversity of etiologies that determine the state of shock and increase morbidity and mortality, especially in post cardiac surgery patients, in whom there are no management emergency postsurgical algorithms. In view of this situation, at the National Institute of Cardiology Ignacio Chávez, a management algorithm has been made and improved in cardiac postsurgical patients: through focused ultrasonography, including transthoracic echography, pulmonary ultrasound, optic nerve ultrasound, and renal ultrasound by evaluating renal resistive indices. Several societies have created their protocols for addressing patients in critical condition, so in the Institute, specifically in cardiovascular intensive therapy, has created the CCROSS protocol (Cardiac, Cerebral, Renal, Optic nerve, lung UltraSound Study) for the initial approach of these patients, and it is being carried out a study for its validation, reproducibility and efficacy.

Cardiac, cerebral, renal, optic nerve, and lung ultrasound study (CCROSS) protocol.

The use of echocardiography is very useful in the evaluation, treatment, and follow-up of the patient in critical condition. Along with clinic and the stethoscope, it is a tool that complements the act of the physician faced with the diversity of etiologies that determine the state of shock and increase morbidity and mortality, especially in post-cardiac surgery patients, in whom there are no management emergency post-surgical algorithms. In view of this situation, at the National Institute of Cardiology Ignacio Chávez, a management algorithm has been made and improved in cardiac post-surgical patients: through focused ultrasonography, including transthoracic echography, pulmonary ultrasound, optic nerve ultrasound, and renal ultrasound by evaluating renal resistive indices. Several societies have created their protocols for addressing patients in critical condition, so in the institute, specifically in cardiovascular intensive therapy, has created the cardiac, cerebral, renal, optic nerve, and lung ultrasound study (CCROSS) protocol for the initial approach of these patients, and a study is currently taking place for its validation, reproducibility, and efficacy.

P311Cardiac damage induced by long term and intensive endurance exercise training in senior athletes: a cardiac magnetic resonance and exercise echocardiography analysis

Abstract Background Moderate intensity regular physical activity is a mainstay of cardiovascular prevention. However, it is under debate whether the cumulative effects of intensive endurance exercise induce chronic cardiac damage. It has been proposed that long-term endurance exercise may be associated with myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR), and/or with right ventricle contractile dysfunction, creating a potential substrate for ventricular arrythmia, but these aspects are not constantly found across studies. Extracellular volume (ECV) determined by CMR, circulating cardiac biomarkers, and longitudinal global 2D strain (LGS) assessed by cardiac echography are relevant tools to explore these potential adverse effects of exercise in senior athletes. Purpose To assess the presence of myocardial fibrosis detected by CMR (LGE and ECV) and biomarkers, and to evaluate ventricles function with LGS, in endurance senior competitive athletes. Methods Thirty-three asymptomatic endurance senior athletes (47±6 years old, 9,6±1,7 h of training per week for 26±6 years), were compared to 18 sedentary controls (49±7 years old). They underwent a CMR protocol including morphological and late gadolinium-enhancement (LGE) analysis, T1 mapping and calculation of ECV using a 1.5 T MRI scanner. A maximal exercise transthoracic echography with LGS analysis was performed. Cardiac biomarkers (N terminal pro brain natriuretic peptide, high-sensitivity troponin T and plasma markers of collagen biosynthesis and degradation procollagen type I N terminal propeptide and procollagen type III NT propeptide) were also analysed. Results Athletes had higher left (84,0±20,8 vs 67,62±12,4 ml/m2; p=0,00593) and right (41,3±9,5 vs 32,9±6,0 ml/m2; p=0,00228) ventricular volumes, higher total biventricular mass (109,61±14,18 vs 98,66±16,25 g/m2; p=0,02038), and higher stroke volume (50,7±12,6 vs 40,1±9,2 ml/m2; p=0,00441) assessed by CMR versus controls. Native T1 (left ventricle: 938±21 vs 940±34 ms; p=0,8098 - right ventricle: 1027±53 vs 1026±114 ms; p=0,92983) and ECV (21,5±1,6 vs 22,0±2,2%; p=0,40868) were not significantly different in athletes compared with controls. LGE was not found in athletes. Peak exercise LGS values were higher in athletes for left (23,19±2,86 vs 20,82±2,05%; p=0,00335) and right (29,25±3,47 vs 26,48±3,22%; p=0,00777) ventricles, compared with control. The levels of cardiac biomarkers were normal in all subjects. Conclusion Athletes showed signs of physiological cardiac remodelling, consistent with previous descriptions of athlete's heart. Despite this important remodelling, there was no evidence of myocardial fibrosis or exercise left or right ventricular dysfunction in athletes. Our results are not supporting the hypothesis of deleterious cardiac effects induced by long term and intensive endurance exercise training.

Pulmonary hypertension in the global population of adolescents and adults living with HIV: a systematic review and meta-analysis

A systematic review and meta-analysis was conducted to estimate the prevalence of PH in adolescents and adults living with HIV at the global level. PubMed, EMBASE, Web of Science, and Global Index Medicus were searched to identify articles published until November 4, 2018. PH had to be investigated with transthoracic echography or right heart catheterization (RHC). A random-effects model was used to pool individual studies. Overall, 25 studies with 42,642 participants from 17 countries were included. One study reported the prevalence of PH among HIV-infected adults based on RHC: 0.5% (95% confidence interval (CI): 0.3–0.6). The global prevalence of PH based on echography was 8.3% (95% CI: 4.6–12.8; 22 studies) among HIV-infected adults. In subgroup analysis, there was no difference between regions, human development indicator, and HIV burden in countries. Among HIV-infected adolescents, the prevalence of PH based on echography was 14.0% (95% CI: 2.2–33.1; 2 studies). This study suggests a high prevalence of PH in the global adolescent and adult population infected with HIV. As such, PH in this vulnerable population should be prioritized by HIV healthcare providers, policy makers and stakeholders for improved detection, overall proper management and efficient control.

Case of a floating right atrial thrombus successfully treated with fibrinolysis

Mobile right atrial thrombi are at high risk of causing massive pulmonary embolism and are a medical emergency. This type of thrombus is identified in about 4-18% of pulmonary embolism cases. The presence of a free-floating embolic mass in right atrial or ventricle is often mortal: the death rate can reach 27%. Although surgery is commonly indicated, fibrinolysis is a therapeutic alternative. Here, a 58-year-old man presented to the emergency department for acute dyspnea associated with a painful right leg. Initial exams showed a shunt effect on blood gases with increased brain natriuretic peptide. Transthoracic echography (TTE) found a free-floating thrombus in the right atrium with signs of pulmonary hypertension and right ventricular dysfunction. Bilateral pulmonary embolism was confirmed by computed tomography angiography. Because there were signs of acute cor pulmonale and no contraindications, treatment with systemic fibrinolysis was decided. The treatment was delivered in intensive care unit and a cardiac surgical team was available. Subsequent clinical improvement was observed. TTE follow up at 12 hours revealed complete thrombus dissolution. There were no complications, in particular no hemorrhage. The patient was discharged after eleven days. At 6 months of follow-up, outcomes with oral anticoagulation therapy were satisfactory. Scintigraphy found good symmetrical perfusion of both lungs with stackable ventilation. TTE at 1 year showed preserved left and right ventricular function with no sign of pulmonary arterial hypertension and no thrombus recurrence. Systemic fibrinolysis appears to be a good alternative to surgery in this case.

Viridans streptococcal infective endocarditis associated with fixed orthodontic appliance managed surgically by mitral valve plasty

Rationale:Streptococcus viridans, a heterogeneous group of alpha-hemolytic streptococci, is part of the normal flora of the mouth, usually responsible for dental caries (Streptococcus mutans, Streptococcus sanguinis), and pericoronitis, as well as for subacute infective endocarditis. They are responsible for 40-60% of the endocarditis cases occurring on the normal valves, especially in male patients and over 45 years of age. A change in the bacterial flora of the oral cavity is taking part after orthodontic fixed appliances are introduced into the oral cavity, change that is associated with an increased concentration of the acidogenic bacteria. Bacteraemia is the consequence of oral cavity infections, the association of infective endocarditis with fixed orthodontic appliance, as it has been described by us for the first time, caused by Abiotrophia defectiva.Patient concerns:We present the case of a female Caucasian patient, aged 22 years, who developed infective endocarditis with Streptococcus viridans associated with fixed orthodontic appliance, located on the mitral valve, without previous cardiac pathology, and the therapeutic difficulties associated with allergic reactions (to vancomycin, and spironolactone).Diagnoses:Repetitive haemocultures were positive with Streptococcus viridans, while transthoracic echography revealed a severe mitral failure through anteromedial segment of the anterior mitral valve leaf prolapse with eccentric jet to the posterior wall.Interventions:During hospitalization, the decision to undergo surgical intervention was taken after obtaining negative haemocultures. The patient underwent surgically intervention, and a mitral valve plasty with insertion of neochords was performed.Outcomes:Intraoperative and subsequently post-discharge transesophageal echography, highlighted normofunctional mitral plasty with a remaining regurgitation grade I-II of IV, with good openness, minor tricuspid regurgitation, and mild pulmonary hypertension.Lessons:Endocarditis with oral streptococci associated with fixed orthodontic appliance seems to be not so unlikely even in young or without previous cardiac pathology patients, requiring attention in identifying possible pre-existing cardiac conditions like mitral valve prolapse with clinical and echographic monitoring of such cases. Educating and motivating the patient to observe the oral hygiene represent key steps for an optimal oral health during orthodontic treatment. Mechanical tooth cleaning helps maintaining a good oral hygiene during fixed orthodontics and decreasing the oral health risks.

Pheochromocytoma as a rare cause of hypertension in a 46 X, i(X)(q10) turner syndrome: a case report and literature review

BackgroundCardiovascular disease (CVD) presents the most serious health problems and contributes to the increased mortality in young women with Turner syndrome. Arterial hypertension in Turner syndrome patients is significantly more prevalent than that in a general age-matched control group. The aetiology of hypertension in Turner syndrome varies, even in the absence of cardiac anomalies and obvious structural renal abnormalities. Pheochromocytoma is an extremely rare cause among various etiologies for hypertension in patients with Turner syndrome. Here, we reported a pheochromocytoma as a rare cause of hypertension in Turner syndrome patient.Case presentationA 21-year-old woman who has diagnosed with Turner syndrome with a karyotype of 46,X,i(X)(q10) visited for hypertension and mild headache. Transthoracic echography (TTE) showed no definite persistent ductus arteriosus shunt flow and cardiac valve abnormalities. Considering other important secondary causes like pheochromocytoma, hormonal studies were performed and the results showed increased serum norepinephrine, serum normetanephrine, and 24 h urine norepinephrine. We performed an abdominal computed tomography (CT) to confirm the location of pheochromocytoma. Abdominal CT showed a 1.9 cm right adrenal mass. I-131 meta-iodobenzylguanidine (MIBG) scintigraphy showed a right adrenal uptake. Laparoscopic adrenalectomy was performed and confirmed a pheochromocytoma. After surgery, blood pressure was within normal ranges and postoperative course was uneventful, and no recurrence developed via biochemical tests and abdominal CT until 24 months.ConclusionOur case and previous literatures suggest that hypertension caused by pheochromocytoma which is a rare but important and potentially lethal cause of hypertension in Turner syndrome. This case underlines the importance of early detection of pheochromocytoma in Turner syndrome. Clinicians should keep in mind that pheochromocytoma can be a cause of hypertension in patients with Turner syndrome.

Percutaneous occluder device closure through femoral vein guidance by transthoracic echocardiography in adult atrial septal defect patients

This study aimed to summarize percutaneous occluder device closure of atrial septal defects (ASD) through the femoral vein, using guidance by transthoracic echocardiography under local anesthesia without radiation or fluoroscopic guidance. This was a case series of fourteen patients, 3 males and 11 females, diagnosed with central ASD, the diameter of the defect ranged from 9 to 32 mm, and the patients had no other heart malformations or organ dysfunction. The patients underwent a novel surgical technique of occluder device closure for ASD. The occluder closure procedures were completed through puncture of the femoral vein, and fluoroscopy-free catheter guidance by transthoracic echography without radiation. All of the cases had successful closure of the ASD, without residual shunt or complications. The median operation time was 18.7±22.5 min (range, 12-56 min), with no ICU-stay time and a short hospital stay of 2.3±0.5 days (range, 1-3 days). All patients were followed up for 2 years and there were no cases of residual shunt. All occluders remained in place. Percutaneous occluder device closure of ASDs through the femoral vein with fluoroscopy-free guidance by transthoracic echography without radiation under local anesthesia could be an easy choice for some simple ASD patients, and may also be favored by cardiac surgeons.

The false aneurysm of the left ventricle complicating mitral valvular surgery

The false aneurysm of the left ventricle is a rare complication after a mitral valvular surgery. It results from the rupture of the ventricular wall inside an adhering pericardium, thus constituting a cavity whose wall is devoid of myocardial elements and communicates with the ventricle by a large collar. Its clinical presentation remains not very specific with an insidious spontaneous evolution which is generally done towards rupture with sudden death by tamponade. Various sophisticated modern diagnostic techniques allows a precise diagnosis. The letal nature of this lesion must be recognized and justifies an immediate surgical repair. We report the case of a 68 years old patient who presented herself in consultation of cardiology with a NYHA IIb (New York Heart Association) cardiac failure 4 months after a surgery of mitral valvular replacement. The transthoracic echography showed a voluminous false aneurysm of the left ventricle confirmed by cardiac CT scan. She has benefited from an anevrismectomy with good clinic evolution. This observation illustrates the late and silent character of the development of the false aneurysm of the left ventricle after mitral valvular surgery.

The Association Between Pulsatile Portal Flow and Acute Kidney Injury after Cardiac Surgery: A Retrospective Cohort Study

Venous congestion is a possible mechanism leading to acute kidney injury (AKI) following cardiac surgery. Portal vein flow pulsatility is an echographic marker of cardiogenic portal hypertension and might identify clinically significant organ congestion. This exploratory study aims to assess if the presence of portal flow pulsatility measured by transthoracic echography in the postsurgical intensive care unit is associated with AKI after cardiac surgery. Retrospective cohort study. Specialized care university hospital. Patients who underwent cardiac surgery between May 2015 and February 2016 and had at least 1 Doppler assessment of portal flow performed by the attending critical care physician during the week following cardiac surgery. The association between portal flow pulsatility defined as a pulsatility fraction ≥50% and the risk of subsequent AKI was assessed using univariate and multivariate logistic regression analysis. The files of 132 consecutive patients were reviewed and 102 patients were included in the analysis. Significant portal flow pulsatility was detected in 38 patients (37.3%) in the week following surgery. During this period, 60.8% developed AKI and 13.7% progressed to severe AKI. The detection of portal flow pulsatility was associated with an increased risk for the development of AKI (odds ration [OR] 4.31, confidence interval [CI] 1.50-12.35, p = 0.007). After adjustment, portal flow pulsatility and AKI were independently associated (OR 4.88, CI 1.54-15.47, p = 0.007). Assessment of portal flow using Doppler ultrasound at the bedside might be a promising tool to detect patients at risk for AKI due to cardiogenic venous congestion.

Optimization of a simultaneous dual-isotope 201Tl/123I-MIBG myocardial SPECT imaging protocol with a CZT camera for trigger zone assessment after myocardial infarction for routine clinical settings: Are delayed acquisition and scatter correction necessary?

BackgroundDual-isotope 201Tl/123I-MIBG SPECT can assess trigger zones (dysfunctions in the autonomic nervous system located in areas of viable myocardium) that are substrate for ventricular arrhythmias after STEMI. This study evaluated the necessity of delayed acquisition and scatter correction for dual-isotope 201Tl/123I-MIBG SPECT studies with a CZT camera to identify trigger zones after revascularization in patients with STEMI in routine clinical settings. MethodsSixty-nine patients were prospectively enrolled after revascularization to undergo 201Tl/123I-MIBG SPECT using a CZT camera (Discovery NM 530c, GE). The first acquisition was a single thallium study (before MIBG administration); the second and the third were early and late dual-isotope studies. We compared the scatter-uncorrected and scatter-corrected (TEW method) thallium studies with the results of magnetic resonance imaging or transthoracic echography (reference standard) to diagnose myocardial necrosis. ResultsSummed rest scores (SRS) were significantly higher in the delayed MIBG studies than the early MIBG studies. SRS and necrosis surface were significantly higher in the delayed thallium studies with scatter correction than without scatter correction, leading to less trigger zone diagnosis for the scatter-corrected studies. Compared with the scatter-uncorrected studies, the late thallium scatter-corrected studies provided the best diagnostic values for myocardial necrosis assessment. ConclusionsDelayed acquisitions and scatter-corrected dual-isotope 201Tl/123I-MIBG SPECT acquisitions provide an improved evaluation of trigger zones in routine clinical settings after revascularization for STEMI.

Clinical Significance of Portal Hypertension Diagnosed With Bedside Ultrasound After Cardiac Surgery.

Portal venous flow pulsatility detected by Doppler ultrasound is a sign of congestive heart failure in noncritically ill patients. The assessment of portal and splenic venous flows has never been reported in patients undergoing cardiac surgery. This is a case series performed in patients undergoing cardiac surgery between February 2014 and February 2015 in which portal and/or splenic venous flows were assessed by the attending anesthesiologist during surgery or by the intensivist after surgery using transthoracic echography in 9 patients or transesophageal echocardiography in 5 patients. Data collection was done retrospectively by reviewing intraoperative and postoperative monitoring documents. The technique of assessment is detailed in this article. We report the abnormal portal and/or splenic venous flow pulsatility from 14 patients perioperatively. At the time of pulsatility detection, patients had a median cumulative fluid balance of 3.8 L (interquartile range: 0-4.6 L) and a median right atrial pressure of 14.0 mm Hg (interquartile range: 12.0-15.5 mm Hg). In some patients (4/14), signs of right ventricular dysfunction on echocardiography and/or right ventricular pressure monitoring were present. Doppler evaluation of portal and splenic venous flow using transthoracic echography and transesophageal echocardiography may represent a promising modality to assess end-organ venous congestion in cardiac surgery patients.

The Influence of Ethnicity in the Relationship between Sedentary Screen Time and Left Ventricular Mass: Insights from the MAG-SALVAGES

Background: The influence of race/ethnicity on the relationship between sedentary screen time and left ventricular mass has been recently suggested, but remains a subject of debate, and has never been explored in Africa. Purpose: To determine whether there is a racial/ethnic influence on the relationship between sedentary screen time and left ventricular mass in MAGhreb and Sub Saharan Africa Left-Ventricul ArGEometry Study (MAG-SALVAGES) participants. Methods: 100 blacks sub-Saharan African and 187 white Maghreb aged 18 - 55 years underwent an interview on their behavioral measures, physical activity and eating habits. Their left ventricular mass has also been measured by a resting transthoracic echography according to the American Society of Echography. Generalized linear models evaluated a test-for-trend across higher levels of sedentary screen time in progressive models with left ventricular measurements as dependent variables. The study population was stratified into quartiles of sedentary screen time (separately for whites and blacks) and examined the joint association of sedentary screen time and LVM within quartiles of physical activity. Results: Among White Maghreb, higher screen time was associated with smaller left ventricular mass (P < 0.001). This association persisted when adjusting for age, gender, heart rate, waist circumference, waist-to-hip ratio, systolic blood pressure QRS duration, TAPS and PAPS. Whereas, in blacks sub-Saharan African, the left ventricular mass was not associated with sedentary screen time. Conclusions: Sedentary screen time is associated with smaller left ventricular mass in White Maghreb, not in black sub-Saharan African. The lack of association in blacks supports a potential qualitative difference in the cardiovascular consequences of sedentary screen based behavior.

0036 : Prognostic value of concomitant aortic regurgitation in patients operated for severe aortic stenosis

The aim of this study was to evaluate the prognostic value of concomitant aortic regurgitation (AR) in patients operated for severe aortic stenosis (AS) by examining the impact of presence and severity of concomitant AR in patients operated for severe AS on short-term outcome. Retrospective study including 37 consecutive patients operated due to severe AS. Patients were divided in two groups, G1: AS group (n=15) and G2: AS + AR (n=22). All patients had a transthoracic echography a week and 6 months after cardiac surgery. Patients mean age was 59,08 with older patients in group 66,16±6,4 vs 54,27±16,3 (p=0,012). 59,5% of the patients were males. Dyspnoea was the predominating symptom (74%) with 40% in stage II and 26% in stage III of NYHA. Coronary artery disease was more frequent in G1 (33% vs 14%; p=0,079, NS). Pre-operative echocardiography showed no difference between the two groups for left ventricular ejection, LV hypertrophy, mean aortic gradients, aortic area and pulmonary pressure. However mean LV diameters were greater in G2 with a mean LV end diastolic diameter (LVEDD) à 58,95±8,4 mm vs 51,2±8,19 mm (p=0,018) and LV end systolic diameter (LVESD) à 39,6±10,5 mm vs 33,2±8,79 mm (p=0,049). Immediate and short-term echocardiographic follow-up showed no difference between the 2 groups. Only LV diameters were greater in G2 avec un LVEDD 59,1 mm vs 51 mm (p=0,03) et LVESD 40,3 mm vs 33,2 mm (p=0,02) à 1 week and LVEDD at 58, 8±9,9 mm vs 50,7±8,19 mm (p=0,032) and LVESD à 40,1±9,7 mm vs 32,8±12 mm (p=0,024) at 6 months. Our data indicate that the preoperative presence of concomitant AR was associated with greater LV diameters. The author hereby declares no conflict of interest

Brucellosis as an Unusual Cause of Mitral Infective Endocarditis

Brucellosis is an infectious disease caused by bacteria. We present the case of 48-years old man, who was admitted for acute renal failure in the context of prolonged fever. Renal biopsy revealed a non specific interstitial nephritis suggesting an infectious origin. Wright serology was positive and a history of unpasteurized milk was confirmed. Two Dimentional Trans thoracic echography 2D (TTE) showed mitral valve vegetation. Despite the initiation of an appropriate antibiotic therapy, the patient experienced embolic episodes that prompted the decision for a surgical treatment. Peroperative examination found a massive infection of the mitral valve and rupture of anterior valvular chordae. Antibiotics were maintained for 6 months with an unremarkable course during follow up.

Ischemic Left Ventricular Perforation Covered by a Thrombus in a Patient Presenting with Cerebral Ischemia: Importance of Time-Sensitive Performance and Adequate Interpretation of Bedside Transthoracic Echography.

If myocardial infarction remains silent, only clinical signs of complications may unveil its presence. Life-threatening complications include myocardial rupture, thrombus formation, or arterial embolization. In the presented case, a 76-year-old patient was admitted with left-sided hemiparesis. In duplex sonography, a critical stenosis of the right internal carotid artery was identified and initially but retrospectively incorrectly judged as the potential cause for ischemia. During operative thromboendarterectomy, arterial embolism of the right leg occurred coincidentally, more likely pointing towards a cardioembolic origin. Percutaneous interventions remained unsuccessful and local fibrinolysis was applied. Delayed bedside echocardiography by an experienced cardiologist demonstrated a discontinuity of the normal myocardial texture of the left ventricular apex together with an echodense, partly floating structure merely attached by a thin bridge not completely sealing the myocardial defect, accompanied by pericardial effusion. The patient was immediately transferred to emergency cardiac surgery with extirpation of the thrombus, aortocoronary bypass graft placement, and aneurysmectomy. This didactic case reveals decisive structural shortcomings in patient's admission and triage processes and underlines, if performed timely and correctly, the value of transthoracic echocardiography as a noninvasive and cost-effective tool allowing immediate decision-making, which, in this case, led to the correct but almost fatally delayed diagnosis.