Evolution of non-invasive myocardial work in tako-tsubo cardiomyopathy

Tako-tsubo cardiomyopathy (TTC) is characterized by left ventricular (LV) systolic dysfunction with transient wall motion abnormalities (WMA). However, whether systolic performance fully recovers is unclear. Non-invasive myocardial work (MW) is a new tool to assess the LV performance, never described in this setting. To assess MW in apical TTC. Fifty patients with the apical variant TTC (77 ± 10 years, 47 women) were enrolled and underwent a transthoracic echocardiography within 24 h of admission and a median of 36 days at follow-up (FU). Constructive work (CW), wasted work (WW), MW index (MWI) and efficiency (MWE) were derived from a strain- pressure loop obtained from non-invasive brachial blood pressure and 2D strain. Hospital complications (HC) were defined as heart failure, LV apical thrombus, and ventricular arrhythmia. A control group of 24 matched-subjects was used. Myocardial work improved significantly between the acute phase and follow-up (global, and all apical and middle segments for all indices, all, p < 0.01; and some basal segments for MWI and CW, all p < 0.05). The degree of impairment of MW followed an apical-basal gradient (worse in apical segments), which inverted at follow-up. Furthermore, in TTC, global CW and MWI were significantly impaired in patients with HC (n = 10, all p < 0.05). At follow-up, global and regional MW remained significantly reduced by comparison to the control group (CW, MWI, MWE, WW, all p < 0.01), despite similar hemodynamics, LVEF and 2D-strain (all, p = NS). Myocardial work is transiently altered in apical TTC and significantly associated to HC. Despite total recovery of WMA, subtle dysfunction of myocardial performance persists at FU.

Evaluation of non-invasive myocardial work in tako-tsubo cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

Tako-tsubo cardiomyopathy (TTC) is characterized by the presence of transient left ventricular (LV) wall motion abnormalities (WMA). However, whether systolic performance fully recover is unclear. Non-invasive myocardial work (MW) is a new index of global and regional myocardial performance which has never been described in this setting. Objective: to assess global and regional MW in typical TTC (apical variant). Methods: fifty patients with typical TTC (mean age, 77 ± 10 years, 47 women) were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24 hours of admission and a median of 32 days at follow-up (FU). MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating in its calculation the non-invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted work (WW) were measured. Hospital complications (HC) were defined as a composite of heart failure, right ventricular extension, and LV apical thrombus. A control group of 24 patients matched for age and sex without overt cardiovascular disease served as a comparative group. Results: In the TTC group, global and regional MW improved significantly between the two examinations (global, regional apical and medial CMW, MWI, MWE, WW, and regional basal CMW, and MWI, all p &lt; 0.01). The acute apical –basal gradient of MW inverted at FU. In TTC, global CMW and MWI were significantly correlated to acute LV systolic function parameters and their change, and were significantly impaired in patients with HC (n = 13) (all, p &lt; 0.01). At FU, despite total recovery of WMA, global and regional MW was significantly reduced in TTC by comparison to the control group (p &lt; 0.01 for all components), although hemodynamics, LV ejection fraction, and 2D global longitudinal strain were similar (all, p = NS). Conclusion: Global and regional myocardial performance is transiently impaired in typical TTC and significantly associated to HC. And despite total recovery of WMA, subtle dysfunction of myocardial performance persist at FU.

Usefulness of non-invasive myocardial work to predict left ventricular recovery and acute complications after acute anterior myocardial infarction treated by primary angioplasty

Background

Predicting left ventricular (LV) recovery after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance.

Objective

To evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV recovery and in-hospital complications after STEMI.

Methods

Ninety-three consecutive patients with anterior STEMI (mean age, 59±12 years) treated by primary angioplasty underwent transthoracic echocardiography (TTE) within 24–48 hours after angioplasty and a median of 92 days at follow-up. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating in its calculation the non-invasive brachial arterial pressure. Segmental LV recovery was defined as a normalization of segmental wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) greater than 5% in patients with baseline LVEF &lt;50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus.

Results

1642 segments were studied and MW was impaired in infarct segments, more severely in no recovery versus recovery segments (MW index, constructive MW, MW efficiency, all, p&lt;0.01). Furthermore, global MW was significantly correlated to acute and follow-up LVEF and global longitudinal strain (GLS) (all, p&lt;0.01). Constructive MW was the best indice to predict segmental (p&lt;0.01 versus MW index, MW efficiency, and wasted work), and global recovery (p&lt;0.05 versus GLS) with an independent association (all, p&lt;0.01). Moreover, global constructive MW was independently associated to in-hospital complications which occurred in 18 patients (p&lt;0.01).

Conclusion

In patients with anterior STEMI treated by primary angioplasty, acute constructive MW is an independent predictor of segmental and global LV recovery, as well as in-hospital complications.

Funding Acknowledgement

Type of funding source: None

The left atrial function is transiently impaired in Tako-tsubo cardiomyopathy and associated to in-hospital complications: a prospective study using two-dimensional strain

Tako-tsubo cardiomyopathy (TTC) is characterized by the presence of transient left ventricular (LV) dysfunction. Whether left atrial (LA) function is also impaired in this setting is unclear. To assess prospectively LA peak systolic longitudinal strain (LAS) by two-dimensional strain at the acute phase of TTC and after recovery and its association with in-hospital complications. 40 patients with typical TTC (mean age 79.5 ± 10 years) underwent transthoracic-Doppler echocardiography at the acute phase and at follow-up (32 ± 18 days later), including the measurement of the LAS (mean of maximal strain from the 4-2 chamber views). A control group of 15 patients (75 ± 7 years, 13 women) without overt cardiovascular disease served as a comparative group. In-hospital complication was a composite of death, heart failure, cardiogenic shock, LV thrombus, and sustained ventricular arrhythmia. In the TTC group, LAS improved significantly between the two examinations from 15 ± 5.5% to 27 ± 8% (p < 0.01) whereas LA volume did not change (p = NS). In the control group LAS was 30 ± 4% (p < 0.01 vs. TTC acute phase, p = NS vs. TTC follow-up). In TTC, at the acute phase LAS was independently correlated to LV global longitudinal strain (LVGLS), and after recovery to E/e', and the change of LAS was independently correlated to the change of the LVGLS (all, p < 0.01). Furthermore LAS was independently correlated to in-hospital complications (p < 0.01). LA function (reservoir) is transiently impaired in TTC and associated to in-hospital complications. Furthermore, the improvement of LAS parallel the dynamic improvement of LVGLS suggests that TTC induces a transient global left heart dysfunction.

P6220The non-invasive coronary flow reserve predicts exercise capacity in patients undergoing cardiac rehabilitation

Background

The benefit of exercise on peripheral muscles is established but the exact role of the coronary microcirculation in exercise capacity after cardiac rehabilitation (CR) is unclear. Objective: Our aim was to test the relationship between non-invasive coronary flow reserve (CFR) and exercise capacity in patients undergoing CR after acute myocardial infarction (AMI).

Methods

CFR was performed by transthoracic Doppler echocardiography in the left anterior descending artery 24 h after angioplasty (CFR1) and after 20 sessions of CR program (at 4±1 months) (CFR2) in 60 consecutive patients (57±11 years, 30% women) with an anterior AMI successfully treated by primary coronary angioplasty. CFR was performed in a modified parasternal view using intravenous adenosine infusion (0.14 mg/kg/min within 2 minutes). CR program consisted of a half hour of fractioned exercise added of a half hour session of general gymnastics and body building. To test the exercise capacity, symptom limited exercise echocardiography was performed just after the CFR2, in a semi-supine position, starting at 25 watts, with 20–25 watts increments of workload every two minutes.

Results

CFR was measured successfully in all patients, and CFR2 was significantly higher than CFR1 (2.9±0.65 vs 1.9±0.4, p<0.001). Though CFR1 was correlated to left ventricular systolic function and its improvement at follow-up (all, p<0.01), CFR2 was independently related to exercise capacity (mean workload 100±30 watts, percent maximal heart rate 83±12%, no ischemia, no new wall motion abnormalities in all tests) after adjusting for age, sex, and body mass index (r=0.6, p<0.01).

Conclusion

CFR predicts exercise capacity in patients undergoing a CR program after AMI. The improvement of CFR contributes to cardiac performance.

[Multiple granular cell tumours in a patient with Noonan's syndrome and juvenile myelomonocytic leukaemia]

BACKGROUND

Granular cell tumour (GCT) is a rare form of tumour comprising Schwann cells. Herein, we report a case of a child presenting Noonan syndrome complicated by juvenile myelomonocytic leukaemia (JMML) and who also developed a multiple form of GCT. We discussed the molecular mechanisms that might account for this association.

PATIENTS AND METHODS

A six-year-old boy with Noonan syndrome complicated by JMML presented three asymptomatic subcutaneous nodules on his back, forearm and neck. Histological analysis revealed GCT. A literature review revealed seven cases of Noonan syndrome presenting GCT, none of which were associated with JMML. Mutation of gene PTPN11, via hyperactivation of intracellular Ras signalling may cause the development of GCT and JMML in children presenting Noonan syndrome.

DISCUSSION

Detailed clinical examination is recommended in children presenting GCT to screen for multiple forms and for signs of malformation suggestive of a genetic syndrome. Ours is the first case to be described of Noonan syndrome complicated by JMML associated with multiple GCT. This association once again raises the important question of the role of the Ras-MAPK signalling pathway in the development of benign and malignant tumours of solid organs or blood, associated with genetic syndromes.

Apical rotation, a simplified index of left ventricular twist is independently linked to recovery after acute anterior myocardial infarction

BACKGROUND

It is unclear whether apical rotation (Ar), which in normal setting represents the dominant contributions to LV twist by comparison to basal rotation (Br), predicts viability in acute anterior myocardial infarction (AMI). Our objective was to test the usefulness of Ar as a simple index to predict LV recovery after AMI.

METHODS

Fourty-five consecutive patients (mean age 60±14 years, mean LVEF 44±7%) with first AMI treated successfully by primary angioplasty underwent prospectively a comprehensive transthoracic-Doppler echocardiography including analysis of Ar, Br, and LV twist by 2-dimensional speckle tracking, using a basal and apical short axis-views, within 24h after angioplasty and 3-6months later. Recovery was defined as: - the normalization of the wall motion of more than 50% of initial abnormal segments (R1) and; - absolute improvement of LVEF≥10% (R2).

RESULTS

A better correlation was found between Ar and LV twist at each stage of the disease than between Br and LV twist (acute phase, R=0.77 vs. R=0.35; follow-up, R=0.9 vs. R=0.3 [all, P<0.001 for Ar, and all, P≤0.05 for Br]). Furthermore, a better correlation was found between Ar and follow-up LVEF (R=0.57), wall motion score index (R=0.44), and global longitudinal strain (R=0.54) (all, P<0.001) than between LV twist and the same parameters (R=0.39; R=0.32; R=0.32 respectively, all P<0.05). (For Br, all, P=NS). Ar as well as LV twist were significantly associated with recovery (all, P<0.01) with an area under the curve (AUC) higher for the former than for the latter (R1, N=18: AUC-Ar=0.81 and AUC-LV twist=0.69, P=0.05; R2, N=19: AUC-Ar=0.82, AUC-LV twist=0.75, P=0.1). In multivariate analysis, Ar remained an independent predictor of recovery R1 and R2 instead of LV twist (all, P≤0.01). Using a ROC curve analysis, the best cut-off of Ar to predict recovery R2 was 6.5°, with Se=77% Sp=85%, P<0.001.

CONCLUSION

Apical rotation is an independent predictor of segmental and global LV recovery after anterior acute anterior myocardial infarction treated successfully by primary angioplasty.

Assessment of left anterior descending artery stenosis of intermediate severity by fractional flow reserve, instantaneous wave-free ratio and non-invasive coronary flow reserve

Assessment of the functional significance of left anterior descending coronary artery (LAD) stenosis of intermediate severity is challenging and often based on fractional flow reserve (FFR). The instantaneous wave-free ratio (IFR), a new vasodilator-free index of coronary stenosis severity, and non-invasive coronary flow reserve (CFR) by transthoracic Doppler echocardiography are also potentially useful. A direct comparison of FFR, IFR, and non-invasive CFR has never been performed. Our objective was to test the usefulness of non-invasive CFR by comparison to invasive FFR and IFR in patients with LAD stenosis of angiographic intermediate severity and stable coronary artery disease.

METHODS

Ninety-four stable consecutive patients (mean age, 68±10years; 19 women) with angiographic proximal or mid LAD stenosis of intermediate severity (40-70% diameter stenosis on quantitative coronary angiography), were prospectively studied. They underwent IFR that was calculated as a trans-lesion pressure ratio during a specific period of baseline diastole, FFR with intracoronary bolus adenosine (180μg), and CFR using intravenous adenosine (140μg/kg/min over 2min) in the distal part of the LAD, the same day. CFR was defined as hyperemic peak diastolic LAD flow velocity divided by baseline flow velocity and FFR as distal pressure divided by mean aortic pressure during maximal hyperemia.

RESULTS

The mean values of IFR, FFR, and CFR were 0.88±0.07, 0.81±0.09, and 2.4±0.6 respectively. A significant correlation was found between CFR and FFR (R=0.63, curvilinear relationship), FFR and IFR (R=0.6, linear relationship), and between CFR and IFR (R=0.5) (all, P<0.01). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR≤0.8, N=31) was IFR≤0.88 with a sensitivity (Se) of 74%, specificity (Sp) of 73%, AUC 0.81±0.04; and CFR≤2 with a Se=77%, Sp=89%, AUC 0.88±0.04, (all, P<0.001). Based on these cut-offs, discordant results between CFR and FFR were observed in 14 cases (agreement 85%), between CFR and IFR in 26 cases (agreement 72%), and between IFR and FFR in 26 cases (agreement 72%).

CONCLUSION

In stable patients with LAD stenosis of intermediate severity, non-invasive CFR is a useful tool to detect a significant lesion based on FFR. Furthermore, there was a better correlation and agreement between CFR and FFR than with IFR.

Assessment of left anterior descending artery stenosis of intermediate severity by fractional flow reserve, instantaneous wave-free ratio, and non-invasive coronary flow reserve

To test the usefulness of non-invasive coronary flow reserve (CFR) by transthoracic Doppler echocardiography by comparison to invasive fractional flow reserve (FFR) and instantaneous wave-free ratio (IFR), a new vasodilator-free index of coronary stenosis severity, in patients with left anterior descending artery (LAD) stenosis of intermediate severity (IS) and stable coronary artery disease. 94 consecutive patients (mean age 68 ± 10 years) with angiographic LAD stenosis of IS (50-70 % diameter stenosis), were prospectively studied. IFR was calculated as a trans-lesion pressure ratio during the wave-free period in diastole; FFR as distal pressure divided by mean aortic pressure during maximal hyperemia (using 180 μg intracoronary adenosine); and CFR as hyperemic peak LAD flow velocity divided by baseline flow velocity using intravenous adenosine (140 μg/kg/min over 2 min). The mean values of IFR, FFR, and CFR were 0.88 ± 0.07, 0.81 ± 0.09, and 2.4 ± 0.6 respectively. A significant correlation was found between CFR and FFR (r = 0. 68), FFR and IFR (r = 0.6), and between CFR and IFR (r = 0.5) (all, p < 0.01). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR ≤ 0.8, n = 31) was IFR ≤ 0.88 with a sensitivity (Se) of 74 %, specificity (Sp) of 73 %, AUC 0.81 ± 0.04, accuracy 72 %; and CFR ≤ 2 with a Se = 77 %, Sp = 89 %, AUC 0.88 ± 0.04, accuracy 85 % (all, p < 0.001). In stable patients with LAD stenosis of IS, non-invasive CFR is a useful tool to detect a significant lesion based on FFR. Furthermore, there was a better correlation between CFR and FFR than between CFR and IFR, and a trend to a better diagnostic performance for CFR versus IFR.

[Voluminous thrombus straddling the patent foramen oval in the setting of massive pulmonary embolism, treated successfully by surgery]

Paradoxical embolism is rarely demonstrated, often suggested, and the diagnosis has been largely presumptive in most cases. The patent foramen ovale (PFO) is an important predisposing anatomic factor for such a complication. We describe a case where a voluminous thrombus straddling the PFO was diagnosed by echocardiography including the 3D modality, in the setting of acute massive pulmonary embolism. The treatment is not codified in this setting, and the thrombus was successfully removed by surgery, associated with PFO closure, and anticoagulation.

Systolic anterior motion of the mitral valve in tako-tsubo cardiomyopathy: Still a matter of debate?

We present a case which developed a typical tako-tsubo-like cardiomyopathy (TTC) during dobutamine stress echocardiography (DSE). Its originality is related to several findings, which have never been described simultaneously in the same patient. This 63-year-old woman with normal coronary angiography and no evidence of coronary vasospasm had a biphasic response to DSE, a finding which usually occurs in coronary artery disease. Moreover, the symmetric extensive wall motion abnormalities (WMA) occurred simultaneously with the development of a systolic anterior motion of the mitral valve (SAM) and left ventricular obstruction, and was clinically asymptomatic. Although in TTC the stunning usually occurs for several days, WMA and SAM resolved within few minutes after cessation of dobutamine and administration of a beta-blocker. And finally, exercise echo performed at the same target heart rate few days later did not induce neither a SAM nor WMA, which suggests that left ventricular obstruction could have played a role in the pathogenesis of this case by supply-demand mismatch. Concomitant coronary microvascular dysfunction was also demonstrated by a reduction of the non-invasive coronary flow reserve in the distal part of the left anterior descending artery.

[Forceps delivery: Professionals' knowledge of forceps application in the area of Lyon]

OBJECTIVES

The aim of this study is to describe knowledge on forceps delivery in the area of Lyon.

MATERIAL AND METHODS

It is a multicentric observational study carried between January 1, 2013 and June 9, 2013. A questionnaire was sent to obstetricians and residents of the area of Lyon. It related prerequisites for operative vaginal delivery, the method used to apply forceps, practices and preferences of operators.

RESULTS

Seventy-five responses were obtained (47 obstetricians, 28 residents). About prerequisites: 6.4% of the obstetricians and 14.3% of the residents never do urinary catheterization. Instrumental delivery is never performed when the fetal head is not engaged. Mid-pelvic operative vaginal delivery is performed by 51.1% of obstetricians. Trans-abdominal ultrasound assessment is conducted in cases of clinical doubts about the fetal head position. For occipital anterior and left anterior positions, the left blade is first applied. A flexion of the fetal head is applied for anterior positions but not in posterior positions. Most of operators do not perform instrumental rotation. Vacuum extractor is the privileged instrument for obstetricians and forceps is often used in second line.

CONCLUSION

This study shows that most of the recommendations for forceps delivery are followed. In front of the lake of statistical power of this study, it might be interesting to improve a largest study with a comparison between obstetricians and residents' practices.

[Incidence, associated factors, and follow-up of hospital heart failure complicating acute anterior myocardial infarction successfully treated by primary angioplasty]

Heart failure (HF) complicating acute myocardial infarction (AMI) is of poor prognosis and is often associated with patient's characteristics and success of reperfusion strategies. However, few data is available regarding the high-risk subgroup of patients with anterior AMI treated successfully by primary angioplasty. The aim of the study was to assess the incidence, associated factors, and the future of HF occurring during hospitalisation, in the setting of anterior AMI treated successfully by primary angioplasty.

METHODS

Eighty-five consecutive patients with anterior AMI treated successfully by primary angioplasty (final angiographic TIMI flow grade=3, without residual stenosis) were included. Clinical, biochemical, angiographic, and echocardiographic data were prospectively collected and compared between patients with (Killip 2 and 3) and without HF during hospitalisation.

RESULTS

Fifteen patients had HF (18%) during hospitalisation and 70 did not. By comparison to patients without HF, patients with HF were more frequently diabetics, had troponin peak and CPK, leucocytes count, and fasting glucose higher, LVEF and wall motion score index in the left anterior descending territory (WMSi-lad) poorer, and a lower non-invasive coronary flow reserve (CFR) in the LAD 24hours after angioplasty (all, P<0.05). In multivariate analysis, fasting glucose, leucocytes count after angioplasty, CFR and WMSi-lad were independently associated with HF, even after adjusting with angiographic variables (all, P<0.05). At 6months, patients with HF had less recovery of LV function and higher frequency of adverse LV remodelling (58% versus 20%, P<0.01) by comparison to patients without HF.

CONCLUSION

In conclusion, HF is not uncommon even after successful primary angioplasty for anterior AMI (nearly one patient out of 5), is associated with hyperglycaemia and inflammation, a poor microvascular reperfusion, and left ventricular systolic function, and is more frequently complicated by adverse LV remodelling and lack of LV recovery.

[Regional recurrence of triple-negative breast cancer: interest of systematic adjuvant lymph node irradiation?]

OBJECTIVE

To evaluate the percentage of regional recurrence (RR) in patients with triple-negative (TN) N0 breast cancer in order to consider the interests of a systematic adjuvant nodal irradiation.

PATIENTS AND METHODS

Between February 1996 and June 2009, 249 patients were treated for TN breast cancer in Léon-Bérard center (Lyon, France). All patients received first surgical treatment followed or not by chemotherapy or radiotherapy. We excluded patients with metastasis at diagnosis, patients who were initially irradiated regional lymph node, patients which ER, PR and/or HER2 status was not known and patients who didn't have standard treatment. Ultimately, 100 patients were included.

RESULTS

Two patients (2%) developed regional recurrence (1 sub and supraclavicular recurrence and 1 supraclavicular recurrence). The median follow-up was 34 months (95% CI: 29,2 to 37,4). The survival rate at 3 years was 98% (95% CI: 90-99). Our study showed no differences in terms of RR between TN cancers and not TN cancers for a median followed up of 34 months.

CONCLUSION

The results of our study do not suggest that patients with TN breast cancer should receive systematic nodal adjuvant radiotherapy.

[Non-invasive coronary flow reserve is an independent predictor of exercise capacity after acute anterior myocardial infarction]

BACKGROUND

After acute myocardial infarction (MI) coronary microvascular impairment and reduced exercise capacity are both determinant of prognosis.

OBJECTIVE

We tested whether non-invasive coronary flow reserve (CFR) performed after MI predicts post-MI exercise capacity (EC).

METHODS

Fifty consecutive patients (pts) (mean age 56.5±11years, 30% women) with a first reperfused ST-elevation anterior MI, and sustained TIMI 3 flow after mechanical reperfusion, underwent prospectively non-invasive CFR in the distal part of the left anterior descending artery (LAD), using intravenous adenosine infusion (0.14mg/kg per minute, within 2min), within 24h after successful primary coronary angioplasty (CFR 1), and 4±1.6months later after a period of convalescence and a cardiac rehabilitation program (CFR 2). CFR was defined as peak hyperaemic LAD flow velocity divided by baseline flow velocity. All pts also underwent semi-supine exercise stress echocardiography (ESE) the same day of CFR 2. ESE was performed at an initial workload of 25-30watts with a 20watts increase at 2-minute intervals. Beta-blockers were withheld 24h before ESE.

RESULTS

The mean CFR 2 increased significantly when compared to CFR 1 (2.9±0.65 versus 1.9±0.4, P<0.01). During ESE, percentage of maximal predict heart rate achieved was 82±12%, maximal workload 95±30watts, exercise duration 486±155s, the ratio of double product 3.1±0.8, and EC 5.8±1.1 metabolic equivalents. No ischemia was induced during ESE in all pts, and the degree of mitral regurgitation did not differ significantly between rest and exercise. CFR 2 was significantly correlated to all indices related to EC (all, P<0.01), whereas CFR 1 was correlated to LV systolic function at follow-up (P<0.05) but not to EC. In multivariate analysis including age, sex, and body mass index, CFR 2 remained an independent predictor of EC (P<0.01).

CONCLUSION

Contrarily to acute CFR, CFR at follow-up is an independent predictor of EC after reperfused anterior MI. This suggests that the improvement of the coronary microcirculation is closely linked to the physical aptitude after MI.

[Assessment of left ventricular twist mechanics by two-dimensional strain in severe aortic stenosis with preserved ejection fraction]

Left ventricular (LV) twist is increased in aortic stenosis (AS) and the hypothesis of a compensatory mechanism is suggested but not established. Our aim was to assess LV twist mechanics in severe AS (<1cm(2) or 0.6cm(2)/m(2)) with preserved LV ejection fraction (LVEF>50%), and to analyze its relationship with LV systolic longitudinal function, early impaired in this setting, LV diastolic function, and symptomatic status.

METHODS

Forty-five consecutive patients with severe AS and preserved LVEF (mean age 73±11 years, 47% female, LVEF 68±11%, 67% symptomatic) underwent a transthoracic echocardiography including a bidimensional strain analysis by speckle tracking method, and were compared to a control group matched for age and sex (n=15). Global longitudinal strain (GLS) was measured using the four, two, and three apical views, and LV twist mechanics from the basal and apical short axis views. LV twist was defined as the net difference between apical and basal rotation, and LV twisting and untwisting rate (in°/s) were derived from twist curves.

RESULTS

Peak apical rotation, LV twist (25±8° vs 20±6), as well as peak systolic and diastolic apical rotation rate, and peak LV twisting rate were significantly higher in patients with AS when compared to controls (all, P<0.05), whereas, the other parameters of LV twist mechanics including basal rotation, were not significantly different between groups. By contrast, the GLS was significantly lower in patients with AS when compared to controls (-17.9±4 vs -20.5±2%, P<0.01). In addition, the GLS was significantly correlated to LV torsion (r=-0.42, P<0.01). Moreover, LV twist progressively impaired with the worsening of diastolic dysfunction and with symptoms onset.

CONCLUSION

LV twist is increased in severe AS with preserved LVEF, compensating the impairment of systolic longitudinal function. However, above a certain threshold LV twist deteriorates, attesting the failure of the compensatory mechanisms, leading to advanced diastolic dysfunction and symptom onset.

[Is it possible to prevent preterm births outside of level-3 maternity wards? Experience of Greater Lyon perinatal network]

OBJECTIVE

The main objective of this study was to calculate the percentage of preterm births before 28 weeks gestational age (weeks GA) outside level-3 maternity wards and determine how many could have been prevented.

METHODS

This was an observational, multicenter, retrospective cohort study, which included all the deliveries that occurred between 24 and 27 weeks GA + 6 days in the Greater Lyon perinatal network (France) occurring between first of March 2008 and first of March 2009. In utero transfers (IUTs) and newborn transfers (NBTs) which were carried out outside the network, medical abortions, and foetal deaths in utero were excluded. The duration between patient's arrival in the level 1 and 2 maternity and birth was compared at the 97(th) percentile of the mother's transfer time in level-3 maternity. Births that occurred outside of level-3 maternity wards were considered avoidable each time the first duration was more than the second.

RESULTS

During the study period, 113 infants were born alive between 24 and 27 weeks GA+6 days in the network. They were all included in the study. Ninety were born in a level-3 maternity ward and 23 were born in level-1 and 2 maternity wards (20%). There were 35 requests for IUT and 28 were carried out (80%). In 65% of non-level 3 births, no IUT was requested. In 17% of cases, an IUT request could have prevented births in level 1/2 maternity wards. If twin pregnancies had been transferred to a level-3 maternity ward, 26% of non-level 3 births would have been avoided. If all high-risk pregnancies had been transferred to a level-3 maternity ward, 40% of non-level 3 births would have been avoided.

DISCUSSION AND CONCLUSION

Any time a pregnant woman is hospitalized in a type 1/2 maternity ward before 28 weeks GA, doctors should consider an in utero transfer to a level-3 maternity ward. It may be possible to lower the birth-rate of non-level 3 births by a targeted increase in in utero transfers and by transferring high-risk pregnancies to a level-3 maternity ward.

[Influence of leukocytes on coronary flow reserve, left ventricular systolic function, and in-hospital events, in patients with acute anterior myocardial infarction treated by primary angioplasty]

OBJECTIVE

To assess the relationship between leukocyte count, non invasive coronary flow reserve (CFR), left ventricular systolic function, and in-hospital adverse events in acute anterior myocardial infarction (AMI) treated by primary angioplasty.

METHODS

Leukocyte count at admission and within 24h after angioplasty, and differential count at admission were obtained in 72 consecutive patients with a first AMI (mean age 56±12 years) successfully treated by primary angioplasty. Transthoracic Doppler echocardiography was performed within 24h after angioplasty and 3 months later to assess the CFR (using intravenous adenosine), in the left anterior descending artery (LAD), left ventricular ejection fraction (LVEF) and the wall motion score index using the nine segments assigned to the LAD territory (WMSi-lad). In hospital events were defined as death, heart failure (Killip≥2) and reinfarction.

RESULTS

Leukocyte count was higher before and after angioplasty in patients with impaired acute CFR (<1.7), when compared to patients without such impairment (P≤0.01), and a significant correlation was found between CFR and leukocyte, neutrophil and monocyte count (P<0.05). Leukocyte (before and after angioplasty), and neutrophil count, were lower in patients with recovery of global and regional LV function (P<0.05). A significant correlation was found between leukocyte count before and after angioplasty, and, initial and follow-up LVEF, and WMSi-lad (all, P≤0.01). Leukocyte (before and after angioplasty) and monocyte count were higher in patients with in-hospital events (n=14), by comparison to patients without events (all, P<0.01). In multivariate analysis, leukocyte count after angioplasty was an independent predictor of CFR, and in-hospital events, and neutrophil count of WMSi-lad at follow-up (all, P<0.05).

CONCLUSION

In the first AMI treated successfully by primary angioplasty, leukocyte count is inversely correlated to CFR, and global and regional LV systolic function at follow-up. These links are higher after than before reperfusion. And, leukocyte count after angioplasty is an independent predictor of in-hospital adverse events.

[Perinatal transfers: survey to evaluate the satisfaction degree of obstetricians and pediatricians with the Rhône-Alpes regional hotline center]

OBJECTIVE

In 2006, the Ministry of Health issued a legal text relating to organization of maternal transports: "By the end of the year 2008, transfers of women and new-born babies will have to be treated in a centralized way", have to provide a 24 hours service and can take several forms such as a regional transfer center, working for several perinatal network or a simple hotline within the level 3 maternity hospital of the perinatal network and would be managed by efficiently trained professionals. In order to help professionals to choose between various types of organizations, we considered to evaluate their degree of satisfaction with the Rhône-Alpes regional hotline center.

PATIENTS AND METHODS

A postal survey was carried out 15 months after the creation of the regional hotline center to the 146 obstetricians and neonatologists of the perinatal network. Eight questions dealt with the following points: organization of in utero transfers and retransfers for obstetricians on the one hand, and the organization of neonatal transfers and retransfers for pediatricians on the other hand.Moreover, several questions relating to the communication quality and the global transport organization were asked to all of these professionals. Finally, practitioners were asked whether the regional hotline center should carry on its activity or not.

RESULTS

The response rate was 51%. Seventy-two percent of practitioners considered the regional hotline center improved the communication between professionals. 66,7% thought that it improved the organization of transport. Obstetricians get benefits in 91,7% of in utero transfers and in 63,8% of retransfers. Neonatologists get benefits in 92,3% of new born babies' transfers and in 53,8% of retransfers. Finally, 85,3% of the doctors felt that the regional hotline center was time saving and 96% of them felt that this structure should carry on its activity.

DISCUSSION AND CONCLUSION

In the French Rhône-Alpes region, most obstetricians and pediatricians are satisfied by a regional hotline center dedicated to in utero as well as neonate transfer.

Scintigraphic imaging of paediatric thyroid dysfunction

Imaging of thyroid dysfunction is safe and clinically relevant in children. In congenital hypothyroidism (CH), thyroid imaging permits a precise characterization of the aetiology, which is important for genetic counselling and clinical management. CH may be due to thyroid dysgenesis (ectopia, hypoplasia and athyrosis) or occurs in eutopic glands. In the latter, hypothyroidism may be either transient, especially after iodine overload, or due to permanent autosomal recessive dyshormonogenesis. Thyroid scintigraphy (TS) with either 99mTcO4 or 123I will identify ectopic thyroid tissue, which is the commonest cause of CH. However, recent reports favour the use of 123I, which enhances the accuracy of the aetiological classification. In cases of eutopic thyroid, the measurement of 123I uptake before and after perchlorate administration evaluates the organification process. At all ages, colour Doppler ultrasound scanning (CDU) is helpful in assessing thyroid volume, in identifying nodules and in characterizing tissue vascularization. TS and CDU images of most paediatric thyroid dysfunctions are presented.

A case of stunning of lung and bone metastases of papillary thyroid cancer after a therapeutic dose (3.7 GBq) of131I and review of the literature: implications for sequential treatments

Thyroid stunning is usually defined as the inhibition or suppression of iodide trapping by remnant thyroid tissue or by functioning metastases following a diagnostic dose of 131I. The risk of stunning increases progressively with larger doses. Because the threshold above which this effect occurs in thyroid remnants seems to be between 37 MBq and 111 MBq of 131I, therapeutic 131I doses of 3.7 GBq may cause stunning. We describe stunning of papillary thyroid cancer lung and bone metastases after a therapeutic dose of 131I (3.7 GBq). A T1 bone metastasis and bilateral lung metastases were diagnosed by post-therapeutic dose whole-body scan. Nuclear MRI detected another lesion at T4, whose 131I fixation was not obvious. An additional 0.7 GBq were given after recombinant TSH, 37 days after the therapeutic dose; 24 h later, uptake by the lung and T1 metastases had disappeared, but trapping was again seen 6 months later on the post-therapeutic scan. This re-appearance is evidence in favour of the transitory and reversible character of stunning, and confirms its correspondence to the decreased ability of viable thyroid cells to trap iodine and not to their destruction. A better understanding of stunning would make it possible, in the event of rapidly progressing disease and in conjunction with recombinant thyroid stimulating hormone (TSH), to give several therapeutic doses of 131I in close succession without each dose hampering the effectiveness of the subsequent one.