Diagnostic Accuracy of Global Longitudinal Strain for Detecting Significant Coronary Artery Disease in Diabetic Patients without Regional Wall Motion Abnormality

AIMS

Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this prospective study was to assess the diagnostic accuracy of global longitudinal strain (GLS) and regional longitudinal strain (RLS) parameters at rest in comparison to stress echocardiography findings for detecting significant coronary artery disease (CAD) in patients with diabetes mellitus (DM).

METHODS

We prospectively studied echocardiographic characteristics at rest with Speckle tracking echocardiography (2D STE) measures; then stress echocardiography and coronary angiography data in 34 diabetic patients without regional wall motion abnormality (RWMA) at rest. Patients were grouped according to coronary angiography and stress echocardiography results into two groups CAD (+) vs control group CAD (-).

RESULTS

GLS at rest was lower in the CAD (+) group ((-14.2 % ± 3.1 vs -17.8 % ± 3.1 in the control group CAD (-), P=0.004). GLS at rest had the highest area under the ROC curve (AUC) (AUC 0.78, sensitivity 61%, specificity 91%,P=0.009) with the cut-off of -14.5% which is equal to predictive power of wall motion scoring index (WMSI) at peak stress to detect significant CAD (AUC=0.76 (95% CI 0.58-0.94, P= 0.016) with the cut-off value of 1.21).

CONCLUSIONS

Global longitudinal strain at rest by STE showed excellent specificity (>90%) and good sensitivity (60%) for the diagnosis of severe CAD among the diabetic population with unknown CAD. This is the first study showing that GLS at rest with cutoff value at -14.5% had good and equal diagnostic accuracy as WMSI at peak stress to detect significant CAD among the diabetic population.

COVID 19 myocarditis: Myth or reality?

COVID 19 so far is not a known cardiotropic virus, and the term “myocarditis” should be exclusively used after EMB or autopsy proven diagnosis. We report a case of 26-year-old man admitted for COVID 19 infection and symptoms leading to myocarditis. We describe the workup that led to the potential diagnosis.

Left ventricular metastasis of osteosarcoma: A report of an unusual case

BACKGROUND

Secondary cardiac tumors are far more frequent than primary tumors. Cardiac metastasis of osteosarcoma is extremely rare.

CASE PRESENTATION

We report a 14-year-old child with left femur osteosarcoma that had metastasized to the left ventricle after 30 months of follow-up. The diagnosis was confirmed based on the findings of transthoracic echocardiography and fluorodeoxyglucose positron emission tomography/computed tomography. Surgical removal was indicated in the patient, but his parents refused this decision, and the patient was discharged and admitted to a pediatric oncology center for chemotherapy. The patient died after four courses of chemotherapy.

CONCLUSION

Cardiac metastasis of osteosarcoma is a strong predictor of disease. The demographic differences shown in our case include male sex and a short interval between onset and cardiac involvement.

Myocardial infarction in a pregnant woman revealing a transitional deficit in protein S: a rare case report

The occurrence of myocardial ischemia and myocardial infarction in pregnancy is relatively rare, the occurrence of myocardial infarction in pregnancy is associated with cardiovascular risk factors. The deficiency of coagulation regulatory systems in the occurrence of venous thrombosis is well established; however, their role in arterial thrombosis is controversial. Here, we present an interesting case of a 34-year-old of acute myocardial syndrome without persistent ST segment elevation, which revealed transient protein S deficiency. Management of acute coronary syndrome (ACS) during pregnancy may represent a unique clinical challenge. In this manuscript, we review the clinical presentation, anatomic considerations, and management strategy in our patient presenting with ACS. Objective: this case highlights the importance of multimodality approach to help to obtain a more timely diagnosis of myocardial infarction in pregnancy and the importance collaboration between obstetricians, cardiologists, pediatricians and anesthesiologists to ensure optimal care.

[Inferior myocardial infarction: first Moroccan study of 103 cases]

L'infarctus du myocarde (IDM) représente une cause majeure de mortalité cardiovasculaire. L'IDM inférieur représente 30 à 50% de l'ensemble des infarctus avec un pronostic favorable par rapport à l'infarctus antérieur. Le but de notre travail est d'étudier les aspects épidémiologiques, cliniques, électriques, échocardiographiques et angiographiques de l'IDM inférieur, ainsi que ses complications et ses modalités thérapeutiques. Sur une période de 3 ans, nous avons admis 720 patients pour ST-Elevation Myocardial Infarction (STEMI) dont 103 de topographie inférieure soit une fréquence de 14,3%. On note une nette prédominance masculine avec une moyenne d'âge de 58 ans pour les hommes et 62 ans pour les femmes. Le tabagisme représente le principal facteur de risque cardiovasculaire retrouvé dans 57,28% des cas. L'infarctus ventricule droit (VD) est objectivé chez 11,65% des malades. La moitié de ces patients ont présenté une instabilité hémodynamique. Le Bicuspid aortic valve (BAV) 3^ème degré a été diagnostiqué chez 12,6% des patients. Sur le plan thérapeutique, sept malades ont été thrombolysés et 42 ont bénéficié d'une coronarographie. La lésion coupable de l'IDM inférieur était la coronaire droite dans 53% des cas et l'artère circonflexe dans 47%. La coronaire droite est responsable de l'infarctus VD dans 100% des cas. L'angioplastie coronaire est réalisée chez 18 patients dans la suite de la coronarographie. Onze malades ont bénéficié d'une angioplastie transluminale (ATL) de la coronaire droite et celle de la circonflexe est réalisée chez 2 malades. La mortalité précoce à 30 jours est estimée à 1,94%. Dans le groupe de patients présentant un infarctus VD, la mortalité est aux alentours de 17%.

[Perforated posterior mitral valve aneurysm: a rare complication of infective endocarditis: a case report]

Mitral valve aneurysm is a rare abnormality whose pathophysiology is poorly understood. It is defined as a bulge of the mitral valve leaflet toward the left atrium. Aneurysm in the posterior leaflet is exceptional. We report the case of a 26-year old man, who had been followed up for rheumatic aortic regurgitation for 4-years, hospitalized for febrile syndrome associated with episodes of left heart failure. Transthoracic echocardiographic examination (TTE) and transesophageal echocardiography (TEE) showed aortic valve vegetations with wide aneurysm of the small mitral valve associated with severe mitral valve regurgitation. The patient underwent mitral and aortic valve replacement with simple postoperative outcome. Clinical suspicion associated with suitable preoperative imaging and early surgical treatment are essential to recognize and treat this rare complication of infectious endocard.

[Infective endocarditis in Morocco through the experience of a hospital department]

Infective endocarditis is a grave disease because of a high level of morbidity and mortality. We conducted a retrospective analysis of 100 patients hospitalized for infective endocarditis from January 2009 until December 2015. The mean age was 41 years with a male predominance. Infective endocarditis occurs on a native valve (77 patients), prosthetic valves (12 patients), Pacemaker (7 patients) and congenital heart disease (4 patients). The diagnostic delay was 77 days on average. The fever was present in 85 patients. Blood cultures were negative in 54 patients. Echocardiography allowed visualizing the vegetations in 95 patients. In patients with prosthetics valves, a paraprosthetic regurgitation was diagnosed in 54 % of these patients and vegetation in 18 %. The main complications are heart failure (42), neurological (19), spleen (10) and renal (23) complications. The evolution under medical treatment was marked by the clinical-laboratory improvement in 57 patients, the lack of improvement with persistent fever in 21 patients. The mortality rate of our series is 23 %. Only seven patients underwent urgent surgery for hemodynamic and infectious indications. At the end of this work, it is emphasized that the epidemiological profile of infective endocarditis does not follow the changes of Wold. Its management is difficult in our context (significant diagnostic delay, often negative blood cultures, high level of morbidity, lack of recourse to early surgery). The improvement of this disease consistes of the prevention of acute articular rhumatism and the establishment of an heart team endocarditis to adapt international recommendations to our context.

Spontaneous rupture of right aortic sinus of Valsalva leading to massive cystic dissection of interventricular septum and complete heart block

The interventricular septal dissection is an uncommon, and is occasionally associated with sinus of Valsalva aneurysm. A spontaneous dissection with a normal sinus of Valsalva is extremely rare and is mostly a result of a congenital defect. We report the case of a 23-year-old male admitted for complete heart block and presenting as an incidental finding during the TTE multiple and huge cystic-like mass in the interventricular septum (IVS) which is the TTE characteristic of IVS dissection. Most patients remain asymptomatic until the anatomical and hemodynamic changes lead to complications like: severe aortic regurgitation with heart failure and conduction abnormalities. Although transthoracic echocardiogram (TTE) has been the first-line imaging modality for such findings, cardiac computed tomography (CT) and magnetic resonance imaging have been increasingly used as supplemental or confirmatory tests. The imaging modalities showed a perforation of right sinus of Valsalva causing the expansion of the dissection to the apex. The patient underwent surgical repair with satisfying results. In conclusion, we report an extremely rare clinical case of spontaneous dissection of the interventricular septum using multiple imaging techniques and with a successful surgery.

[Management of multiple valve disease]

Polyvalvular disease is not a rare condition, the lack of specific data for each situation does not allow perfoming standardized management and guidelines. We want to present by this review available data on the management of polyvalvular disease, taking into account different possible associations between the valve lesions.

[A cardiac rhabdomyome evoking the antenatal diagnosis of a Bourneville's tuberous sclerosis]

Rare hereditary affection, the Bourneville's tuberous sclerosis (BTS) is an autosomal dominant inherited phakomatosis. Rhabdomyomes are the most frequent cardiac tumors in children and infants, they are one of the most premature modes of revelation of the STB. They sometimes allow to envisage the diagnosis in antenatal period at the same time as the genetic and neurological explorations. We report the diagnosis of a fetal BTS evoked by the antenatal discovery of a cardiac rhabdomyome. The antenatal cerebral explorations, realized by magnetic resonance imagery (MRI), put evidence cerebral localisations confirming the diagnosis.

Atteinte cardiaque au cours de la dystrophie myotonique de Steinert: expérience marocaine, à propos de 18 cas

La maladie de Steinert ou dystrophie myotonique de type 1 (DM1) est une maladie génétique à transmission autosomique dominante caractérisée par une myotonie et une atteinte de plusieurs organes dont le cœur. L'atteinte cardiaque est la plus grave des atteintes systémiques puisqu'elle conditionne le pronostic vital. Ce travail a pour but de déterminer les anomalies cardiaques rencontrées au cours de la DM1 et de mettre en exergue l'intérêt d'un examen cardiaque rigoureux et régulier, indépendamment de la sévérité de l'atteinte neuromusculaire, ainsi que l'apport des examens cardiaques complémentaires et notamment l'exploration électrophysiologique. 18 patients atteints de DM1 ont bénéficiés d'une exploration cardiaque systématique. Il s'agit de 9 hommes et de 9 femmes, d’âge moyen de 41,8 +/- 16,2 ans. 66 p.100 des patients sont symptomatiques sur le plan cardiovasculaire. Les anomalies électrocardiographiques sont dominées par un trouble de la conduction intra-ventriculaire dans 16 p.100 des cas et un BAV de 1er degré dans 16 p.100 des cas. L'Holter ECG objective une hyperexcitabilité à l’étage atrial et/ou ventriculaire dans 50p.100 des cas. L'ETT est normale chez 95 p.100 des patients. L'exploration électrophysiologique, réalisée chez 4 patients symptomatiques, a objectivé un bloc tronculaire dans un cas ayant conduit à l'implantation d'un PM double chambre. Un seul patient est décédé suite à une détresse respiratoire. Enfin, on n'a pas noté de corrélation entre l'atteinte cardiaque et neuromusculaire. Une exploration cardiaque est indispensable chez tout patient atteint de DM1, en dépit de l'absence de symptômes, et un bilan annuel minimal s'impose pour guetter un éventuel trouble rythmique et/ou conductif, fatal en l'absence de traitement adéquat.

[Atrioventricular block after cardiac surgery: report of 23 cases]

Le bloc auriculo-ventriculaire (BAV) représente une complication non négligeable de la chirurgie cardiaque. Il est responsable de séquelles lourdes et graves compromettant le pronostic de la maladie et conduisant à la mise en place d'un stimulateur cardiaque définitif. Il est primordial d’étudier et de déterminer les différents facteurs prédictifs de BAV post opératoire, son histoire naturelle, son incidence ainsi que le délai exact de la mise en place d'un pacemaker. Notre étude est une étude rétrospective descriptive à propos de 23 patients opérés pour chirurgie cardiaque sous circulation extracorporelle entre octobre 1989 et août 2010 ayant présentés des troubles conductifs auriculo-ventriculaires en post opératoire. Plusieurs facteurs de risque ont été étudiés dans notre série, liés surtout à l'atteinte directe du noeud auriculo-ventriculaire ou à l'ischémie myocardique. Le délai d'apparition du trouble conductif ainsi que le délai d'implantation on été également étudié. Plusieurs facteurs favorisants de survenue de BAV ont été identifiés liés essentiellement au type de la cardiopathie opérée avec une prédominance de la cardiopathie congénitale, d'autres facteurs ont été rapportés notamment la présence d'hypertrophie ventriculaire gauche (HVG) de troubles conductifs en préopératoire, une durée du clampage aortique et de CEC prolongée. La moitié des patients ont présenté un BAV immédiat. Le délai d'implantation par rapport à la date de la découverte du BAV varie dans notre série d'une implantation immédiate après le diagnostic positif (J0) à un délai d'implantation allant jusqu’à 57 jours. Plusieurs facteurs de risques déterminent la survenue de BAV post chirurgie cardiaque, leur connaissance est primordial ainsi que le délai exact de l'implantation du stimulateur cardiaque définitif.

Unusual findings in secondary hypertension: double orifice mitral associated to aortic coarctation, bicuspid aortic valve, and ventricular septal defect

Double orifice mitral valve is a rare congenital anomaly presenting as the division of the mitral orifice into two anatomically distinct orifices, it is most often associated with other congenital heart defects such as left-sided obstructive lesions, ventricular septal defects or aortic coarctation. We report the case of a 15 year’s old boy, admitted for arterial hypertension, auscultation revealed a rude aortic systolic murmur. Femoral pulses were weak. Owing to the suspicion of aortic coarctation, transthoracic echocardiography was performed, the aortic coarctation with dilation of the aorta proximal to the stenosis was confirmed and bicuspid aortic valve was found with good function. The mitral valve was dysmorphic, having two orifices; it was divided into 2 separate valve orifices by a fibrous bridge. No mitral or aortic regurgitation was documented by color Doppler flow imaging. The left ventricular ejection fraction was normal. There was a small peri membranous ventricular septal defect with left to right shunt. Owing to the severity of the aortic coarctation and taking into account the anatomy and characteristics of the patient, he was made a surgical correction of aortic coarctation with good outcome.

[Isolated left ventricular congenital diverticulum in adult: Report of cardiac imaging]

Cardiac diverticulum is an infrequent congenital malformation, it's even more rare in adulthood. It's often associated with other thoraco-abdominal diverticulums, and rarely isolated. The diagnosis relies on echocardiography. By the way, the magnetic resonance imagery (MRI) allows a finer analysis of the diverticulum, its topography and its situation contributed to vascular and cardiac structures, it has largely replaced the ventriculography. We report in this article the case of a patient of 36 years whose diagnosis of the diverticulum was made by transthoracic echocardiography (TTE) at the time of an assessment of dyspnea, this exam also objectified a mitral insufficiency by deformation and dilatation of the mitral annulus. Radiological assessment was completed by a transoesophageal echocardiography (TOE) and magnetic resonance imagery (MRI). Surgical treatment consisted of surgical closing of the diverticulum and mitral annuloplasty.

[The role of multimodality imaging in the diagnosis of constrictive pericarditis]

Constrictive pericarditis is a rare heart disease. The diagnosis remains a challenge. In fact, this illness can mimic restrictive cardiomyopathy. Echo-Doppler evaluation helps to establish the diagnosis of constriction; however, this technique is limited in its ability to image the entire pericardium because of its limited acoustic windows by air or bone of thorax. In addition, it is an operator-dependent exploration. Scanner and magnetic resonance imaging provide a large field of view and excellent images, showing the increased pericardial thickness and septal motion abnormalities. This review will consider the emerging role of these imaging modalities in the constrictive pericarditis diagnosis.

Insights from magnetic resonance imaging of left ventricular non-compaction in adults of North African descent

Background

Left ventricular non-compaction (LVNC) is a recently recognized rare disorder. Magnetic resonance imaging (MRI) may help to clarify the uncertainties related to this genetic cardiomyopathy. Despite the fact that many articles have been published concerning the use of MRI in the study of LVNC, there is a lack of data describing the disease in the North African population. The aim of our study is to clarify MRI findings of LVNC in North African patients.

Methods

In our retrospective cohort, twelve patients (7 male, mean age 53 ± 8 years) underwent MRI for suspected LVNC. Correlations were investigated between the number of non-compacted segments per patient and left ventricular ejection fraction (LVEF), then between the number of non-compacted segments and left ventricular end diastolic diameter. The presence or absence of late gadolinium enhancement (LGE) was qualitatively determined for each left ventricular myocardial segment.

Results

Non-compaction was more commonly observed at the apex, the anterior and the lateral walls, especially on their apical and mid-cavity segments. 83% of patients had impaired LVEF. There was no correlation between the number of non-compacted segments per patient and LVEF (r = -0.361; p = 0.263), nor between the number of non-compacted segments per patient and left ventricular end diastolic diameter (r = 0.280; p = 0.377). LGE was observed in 22 left ventricular segments. No association was found between the pattern of fibrosis and non-compaction distribution (OR = 2.2, CI [0.91-5.55], p = 0.076).

Conclusion

The distribution of LVNC in North African patients does not differ from other populations. Ventricular dysfunction is independent from the number of non-compacted segments. Myocardial fibrosis is not limited to non-compacted areas but can extend to compacted segments.