Abstract Introduction Patent foramen ovale is a fairly common defect found in a quarter of the population. PFO has always been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi passing through the PFO directly into the left atrium, however this mechanism remains debated to date. For the detection of PFO, several modalities exist including transcranial doppler (TCD), transthoracic echocardiography (TTE) and transoesophageal echocardiography. This raises the question of the examination with the best diagnostic performance for its detection. Purpose The majority of studies comparing the different modalities of patient PFO diagnosis have been conducted in the context of stroke assessment. Very few studies have focused on the acute PE patient population. The interest of our study is therefore to evaluate the diagnostic performance of two modalities (TTE versus TCD) for the detection of shunts, especially since this population is at risk of stroke by paradoxical embolism due to the phenomenon of hyperpressure in the right heart chambers increasing the chances of having a paradoxical embolism. Methods We performed a post HOC analysis of the EPIC-FOP study which is a multicenter, prospective, French cohort study. Patients were recruited within 3 days of diagnosis of PE. Patients included were given a transthoracic echocardiography (TTE) with PFO screening by injection of saline contrast and magnetic resonance imaging (MRI) within 7 days of inclusion to look for signs of recent stroke. A proportion of the patients included in this study also received a transcranial doppler in search of PFO, the results of which were used in our study. Results The mean age of the patients was 62±14.66 years with a slight male predominance (55.6%). TCD was able to detect 97 right-left shunts while the TTE detected only 25 shunts. Concordance analysis by Cohen's Kappa Coefficient: 0.1767 [0.0427; 0.3107–p<0.001] is considered poor. Using TTE as the reference examination, transcranial Doppler has a very good sensitivity 96.00% (79.65% to 99.90%) and a poor specificity 42.06% (33.33% to 51.18%). A good negative likelihood ratio 0.10 (0.01 to 0.66). Using TCD, incidence of stroke in the acute phase of PE was significantly higher in the PFO population. In the ten strokes detected 9 had occurred in patients with PFO, RR=1.43 IC95% (1.1169 to 1.8228) p=0. 0044. The difference in proportion is calculated to be 26.92%. Conclusion It is the first study that compared TCD vs TEE in the setting of acute phase of PE for detection of PFO. TCD showed a good sensitivity and negative likelihood ratio that can be used as a first means to rule out PFO or associated with TTE. Also, our analysis confirms the increased risk of stroke following a PE episode when a PFO is present. Funding Acknowledgement Type of funding source: None

Aims The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE). Methods and results Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, F-18-fluorodeoxyglucose positron emission tomography/computed tomography (F-18-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). F-18-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated. Conclusion Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.

Aims The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) European Endocarditis (EURO-ENDO) registry aims to study the care and outcomes of patients diagnosed with infective endocarditis (IE) and compare findings with recommendations from the 2015 ESC Clinical Practice Guidelines for the management of IE and data from the 2001 Euro Heart Survey. Methods and results Patients (n = 3116) aged over 18 years with a diagnosis of IE based on the ESC 2015 IE diagnostic criteria were prospectively identified between 1 January 2016 and 31 March 2018. Individual patient data were collected across 156 centres and 40 countries. The primary endpoint is all-cause mortality in hospital and at 1 year. Secondary endpoints are 1-year morbidity (all-cause hospitalization, any cardiac surgery, and IE relapse), the clinical, epidemiological, microbiological, and therapeutic characteristics of patients, the number and timing of non-invasive imaging techniques, and adherence to recommendations as stated in the 2015 ESC Clinical Practice Guidelines for the management of IE. Conclusion EURO-ENDO is an international registry of care and outcomes of patients hospitalized with IE which will provide insights into the contemporary profile and management of patients with this challenging disease.

Methods: One hundred patients referred for CABG were randomly assigned to FFR-guided or angiography-guided CABG.Based on the coronary angiogram, a heart team made a graft plan in all patients.FFR was measured in accessible lesions planned for grafting.In FFR-guided CABG, coronary lesions with FFR>0.80 were deferred, while the surgeon was blinded to the FFR-values in the angiography-guided CABG group.Angiographic follow-up after 6 months evaluated graft failure in all grafts and FFR in deferred lesions.Graft failure was defined as under TIMI 3 flow and/or >50% anastomosis stenosis.This study presents graft failures in lesions with FFR>0.80 versus lesions with FFR≤0.80 and changes in FFR in deferred lesions after 6 months.Results: Index FFR measurements were obtained in 97 (97%) patients leaving 49 patients in the FFR-guided group and 48 patients in the angiography-guided CABG group.Angiographic follow-up after 6 months was available in 72 (74%) patients and in 107 (66%) of the 161 lesions, preoperative evaluated with FFR, 81 of these lesions were grafted and 26 lesions were deferred.Graft failure of all grafts was 10% in grafts to lesions with FFR>0.80 (n=20) and 8% in grafts to lesions with FFR≤0.80 (n=61) (p=0.80).Graft occlusions occurred in 5% of grafts to lesions with FFR>0.80 and in 8% of grafts to lesions with FFR≤0.80 (p=0.53).Deferred lesions (N=24) showed a significant reduction in mean FFR from index to follow-up (0.89±0.05 vs. 0.81±0.11,p=0.002).In lesions with angiographic moderate stenosis and preoperative FFR>0.80, 9 (37.5%)deferred lesions had FFR≤0.80 at follow-up compared to 2 (10%) graft failures (p=0.044).Conclusions: FFR evaluations before CABG did not improve graft patency after 6 months.Deferred lesions showed a significant reduction in mean FFR from index procedure to follow-up after 6 months.

Le risque d’accident ischémique cérébral (AIC) est plus élevé chez les patients présentant un foramen ovale perméable (FOP), mais le mécanisme des AIC reste controversé (trouble du rythme, anomalie septale ou embolie paradoxale ?). Notre hypothèse était que l’embolie paradoxale était le mécanisme principal. Nous avons donc comparé la prévalence des AIC récent chez les patients ayant un embolie pulmonaire (EP) symptomatique, selon la présence ou non d’un FOP (étude EPIC FOP ; NCT01216423). Dans une étude prospective chez 374 patients ayant une embolie pulmonaire documentée, nous avons réalisé de façon systématique une IRM cérébrale dans les 15 jours suivant la survenue des signes cliniques d’embolie. Le diagnostic d’AIC récent était retenu en cas d’hypersignal sur les images pondérées et de diminution de l’ADC. Le FOP était détecté par échographie transthoracique avec test de contraste (ETT-c). Un shunt artérioveineux était par ailleurs recherché par doppler transcrânien (DTC). La prévalence des AIC récents symptomatiques ou silencieux était comparée chez les patients présentant ou non un FOP. La recherche de FOP par ETT-c a été concluante chez 324 patients (43 patients avec FOP et 281 patients sans FOP). L’âge moyen des patients était de 66 ans (interquartile : 54–77). Une thrombose veineuse profonde était associée à l’EP dans 45 % des cas et le score de gravité était nul chez 55 % des patients (pas de différence significative entre les groupes avec FOP et sans FOP). Un patient dans le groupe avec FOP et 8 patients dans le groupe sans FOP ont été exclus car ils n’ont pas eu d’IRM dans le délai prévu de 15 jours. La prévalence des AIC récents était significativement plus élevée dans le groupe des patients présentant un FOP que chez les patients n’ayant pas de FOP (respectivement 9/42 [21,4 %] et 15/273 [5,5 %], test de Fisher p = 0,0016). Les AIC symptomatiques étaient plus fréquents dans le groupe avec FOP (4 patients [9,3 %] versus 4 patients [1,5 %]). Lorsque l’on compare la prévalence des AIC récents en présence d’un shunt artérioveineux dépisté par ETT-c et/ou DTC, elle est plus élevée que chez les patients sans shunt (respectivement 14 % et 3,6 %, p = 0,0007). Nous avons mis en évidence chez des patients présentant une embolie pulmonaire, une augmentation de la prévalence des AIC récents, chez les patients présentant un FOP en comparaison des patients n’ayant pas de FOP. Cette différence confirme que l’embolie paradoxale est un mécanisme important des AIC chez les patients présentant un FOP. Ce mécanisme doit être pris en compte dans la prévention de la récidive des AIC chez les patients présentant un FOP.

Benfluorex’s imputability in drug-induced valvular heart disease (DIVHD) is now well established. However no data about long term clinical and echocardiographic follow-up of patients suffering from benfluorexrelated DIVHD are available. The present study was conducted to address this issue. Between January 2003 and June 2012, after an exhaustive analysis of our database, 20 patients (55±9 years, 90% women, body mass index: 32.9±9 kg/m²) hospitalized for heart failure were retrospectively identified with benfluorex induced moderate or severe mitral regurgitation (MR). Initially 70% of them presented NYHA class III or IV. MR was quantified as moderate in 11, moderate to severe in 8 and severe in one patient. Aortic regurgitation (AR) was also present in 17 patients (85%): mild in 5, moderate in 9 and moderate to severe in 3 patients. During a median follow-up of 7 years, heart failure episodes led to 53388 Valve replacements. Two patients died, one in the surgical group and one in the medical group. Among survivors, NYHA class improved in 6 patients in the surgical group but only in 4 in the medical group. After withdrawal of benfluorex, MR decreased in 7 patients and AR decreased in 5 patients. MR was stable in 3 patients and AR in 4 patients. A worsening of MR was not observed and AR worsened in 2 patients. After an hospitalization for a first episode of heart failure related to benfluorex-induced MR, patients are exposed to a large number of cardiac events including repeated hospitalizations and death.

Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries.

UNLABELLED:Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries.METHODS:We ran a retrospective monocentric study in the "Clermont-Tonnerre" military hospital in Brest. We included all patients sent for TEE, aged 15 to 30 years old, from the 1st January 2010 until the 31st July 2013.RESULTS:Two hundred and eighty TTES assessing CSM were performed. We found 28/280 (10%) echocardiographic abnormalities: 13 were bicuspid aortic valves (4.6%), 6 were ventricular septal defects (2.15%), 3 were atrial septal defects (1.07%), 4 were mild mitral regurgitations (1.43%), one mild pulmonary stenosis (0.35%) and one aortic stenosis (0.35%). No hypertrophic cardiomyopathy was found. Concerning military expertise, 11 (3.92%) patients among these 28 with abnormal TEE were considered unfit for work or "fit for work with limitations".CONCLUSION:Assessing a cardiac systolic murmur with TEE lead to the diagnosis of a cardiomyopathy in 10% of the case. This study enhances the importance of systematic TEE when a CSM is detected in the young military, in order to determine if those soldiers can still fulfill their military duty.

Diagnosis of Whipple's disease is difficult, and thus its frequency is probably underestimated, particularly in culture-negative infective endocarditis. However, it must be systematically searched for in such a situation, first because it is associated with a poor natural outcome, and second because Tropheryma whipplei is not covered by the conventional empirical therapy recommended for culture-negative infective endocarditis. Whipple's disease endocarditis is usually associated with weight loss, intestinal and joint involvement. Nevertheless, it is sometimes the only manifestation of the disease, which makes the diagnosis much more difficult. We report the case of a 66-year-old patient with Barlow's disease, who underwent mitral valve replacement for severe mitral regurgitation. Vegetations were observed on the resected valve, both macroscopically and histologically. No microorganism was found at first. The diagnosis of Whipple's disease endocarditis was finally obtained by Polymerase Chain Reaction on valve tissue, and later confirmed by Periodic Acid Schiff staining. The outcome was favorable after a prolonged antibiotic therapy including doxycycline and hydroxychloroquine.

Recent case reports suggest that benfluorex, a fenfluramine derivative used in the management of overweight diabetic patients and dyslipidemia, is associated with cardiac valve regurgitation.We conducted a case-control study. Eligible patients were those admitted in the cardiology or the cardiac surgery units of our hospital between January, 1(st) 2003 and June 30(th) 2009, with mitral insufficiency diagnostic codes (ICD-10 I340 and I051). Patients with either a primary cause (degenerative, known rheumatic heart disease, infectious endocarditis, congenital, radiation-induced valvular disease, associated connective and/or vasculitis disease, trauma, tumor) or a secondary (functional) cause were considered as having an "explained" mitral regurgitation. Other patients were considered as having an "unexplained" mitral regurgitation and were included as cases. For each case, two controls were matched for gender and for the closest date of birth, among a list of patients with an "explained" mitral regurgitation. Drug exposures were assessed blindly regarding the case or control status, through contacts with patients, their family and/or their physicians.Out of the 682 eligible patients, 27 cases and 54 matched controls were identified. The use of benfluorex was reported in 22 patients: 19 of the 27 cases, versus 3 of the 54 controls, odds-ratio 17.1 (3.5 to 83), adjusted for body mass index, diabetes and dexfenfluramine use.The use of benfluorex is associated with unexplained mitral regurgitation.

Since 1976, benfluorex has been approved in Europe as a hypolipidemic and hypoglycemic drug, and is commonly used in the treatment of the metabolic syndrome. As a derivative of fenfluramine with an appetite suppressant action, benfluorex is preferentially used in overweight patients. In contrast to fenfluramine and dexfenfluramine, to date, benfluorex has not been reported to be associated with frequent cardiovascular side-effects. The present study reports five cases of severe pulmonary arterial hypertension and one case of valvular heart disease occurring in patients exposed to benfluorex. These individuals were middle age, diabetic females with a body mass index ranging 24.2–49 kg·m−2. No definite causal effect for cardiovascular disease with benfluorex can be drawn from such case reports. However, as benfluorex, like dexfenfluramine and fenfluramine, is metabolised into active metabolite norfenfluramine, further extensive assessment of drug exposure in newly diagnosed pulmonary arterial hypertension or valvular heart disease patients is warranted.

Objective. - To describe the features of pulmonary arterial hypertension (PAH) in elderly patients.Methods. - A single centre, descriptive study of PAH patients consecutively referred to a regional centre, from September 2002 to February, 1st, 2009. The group of patients aged 65 and above at the time of the diagnosis was compared to the younger patients.Results. - Sixty-six patients suffering from PAH (group 1) have been investigated by means of right heart catheterisation. There were 24 patients aged 65 and above. Mean pulmonary arterial pressure was tower in the patients aged over 65. The older patient group had more respiratory and/or cardiac co-morbidities, a lower median distance in the 6 minute walk test and a higher median Pro-BNP level. Specific PAH treatments were prescribed in both groups. Fifteen patients aged 65 and above were on long-term oxygen therapy (vs four younger patients, p < 0.0001). The elderly patients had a median survival of 32 months.Conclusion. - The diagnosis of PAH in elderly patients is associated with a poor prognosis. The management of these patients needs further studies. (C) 2009 Published by Elsevier Masson SAS.

Background: Currently, two sputum colour charts (SCC) are used in bronchiectatic disease. The SCC developed by Stockley1, consists of 9 colour fields. The SCC developed by Murray2, encompasses 8 sputum photographs. Both SCC have arbitrary gradations and are rather difficult to reproduce. Aimes: Development of a continuous, standardized and easy to reproduce SCC, based on the Natural Colour System (NCS). Methods: Every colour has an NCS code, composed of a darkness, a saturation and a hue. By comparing the photographs of the Murray chart with the NCS, we selected corresponding NCS hues. We have modified the saturation and darkness for each hue in order to achieve 17 successive colours per hue. The achieved colours were inserted in a 17x4 table. Printing with Docucolor 242 Xerox laser printer; brightness 85%. Results: A new, reproducible 17-part SCC, built up with NCS colours (figure 1). The spectrum is ranging from bright yellowish/greenish colours (low saturation-low darkness) to dark brown/green colours (high saturation-high darkness). In the vertical direction each section is composed of equivalent boxes that have a different hue but otherwise the same properties (same saturation and darkness). Conclusions: We developed a fluent, reproducible 17-part SCC encoded in the NCS. Further research is needed to assess its reliability and to evaluate the number of categories. 1Stockley RA et al. Thorax 2001 2Murray MP et al. Eur Respir J 2009.