Biomedical subjects
Publications and source records attributed to L Fourcade.
We describe the case of a fatal cerebral hemorrhage associated with a severe thrombocytopenia (4.0 x 10(9)/l), occurring only 90 min after starting treatment with abciximab, in a patient undergoing primary percutaneous transluminal coronary angioplasty (PTCA) for an acute myocardial infarction. Cathet. Cardiovasc. Intervent. 49:177-180, 2000.
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Since emergency transfer of patients from Africa to European cardiovascular facilities is difficult, surgeons at the Principal Hospital in Dakar, Senegal, have reevaluated closed mitral commissurotomy. The purpose of this study was to ascertain patient selection criteria, optimal operative conditions, immediate and middle-term outcome, and cost of closed mitral commissurotomy. From June 1995 to March 1998, closed mitral commissurotomy was carried out on 21 patients (13 women and 8 men). Inclusion criteria were symptomatic mitral stenosis with a mitral surface less than 1.5 square centimeters. Exclusion criteria were associated valve disease, Wilkins score higher than 8, severe pulmonary artery hypertension, and evidence of mitral thrombus. One patient died on the fourth postoperative day and one patient developed transient hemiparesis. Twenty patients showed significant functional improvement. Mean mitral surface increased from 0.87 to 1.8 square centimeters. Follow-up at one-year confirmed stable results. Only one patient developed grade 3 mitral insufficiency but it was well tolerated and did not require valve replacement. The cost of the procedure was 1,000,000 F CFA in second category and 820,000 F CFA in third category. The findings of this study show that closed mitral commissurotomy can be performed without circulatory assistance equipment in African facilities such as the Principal Hospital in Dakar, that immediate and middle-term results are excellent, and that African surgeons should continue to learn the technique.
The immediate results of transluminal coronary angioplasty (TCA) have improved considerably during recent years. Balloon dilatation of the arterial stenosis is the basis of this technique of revascularisation but new tools may be used to treat specific lesions. Coronary occlusion is the most feared complication of TCA. It may cause myocardial infarction or death of the patient. It is usually secondary to dissection and/or thrombus of the artery. The implantation of a stent successfully treats most cases of dissection. New anti-platelet (GP IIb/IIIa) drugs seem to be very effective in the prevention and treatment of the thrombosis. The systematic use of ticlopidine limits the risk of stent occlusion. Improved features enable satisfactory implantation of stents in the majority of cases. In some patients, the clinical consequences of occlusion may be limited by vascular bypass techniques, especially intra-aortic balloon pumping. In other cases, emergency coronary bypass surgery may be necessary. When TCA is considered to be a very high risk procedure, effective surgical cover is essential.
The clinical presentation of malaria is, in most of cases, a malaria attack. It occurs in 90% of imported cases in France within 30 days after return of endemic area. Characteristic malaria paroxism have three stages: chills, high fever (> 39 degrees C) and sweating stage. In this typical form, parasitaemia is easily disclosed. With the increasing spread of chemoresistance P. falciparum strains, many patients experience non specific symptoms before the onset of paroxysm, often complaining of malaise, headaches, myalgias and anorexia. In some cases temperature did not exceed 38 degrees C and physical examination revealed sometimes liver or splenic enlargement. These atypical presentations can masquerade other diseases such as a viral illness. In those patients blood smears were often negative and malaria diagnosis is carried out only by QBC or parasight test. Treatment of malaria attack needs antimalarial drugs effective against chemoresistant P. falciparum strains. Mefloquine of halofantrine can be delivered with the respect of guidelines prescription, given major side effects observed with these drugs (neuropsychiatric disorders with mefloquine and cardiac arrhythmias with halofantrine). Oral quinine sulfate can be used when the above drugs are not allowed.
The tilt table is a diagnostic device used to induce vagal syncope and determine etiology. Sensitivity enhancing techniques, such as the administration of isoproterenol, can be applied to children and young adults to compensate for the otherwise low sensitivity (20%-30%) observed in that population. This study describes an improved test that offers a simplified approach while decreasing the amount of time involved by up to 50%, without compromising sensitivity. This 45-minute procedure relies on sensitization with isoproterenol administered as a 2- to 80 micrograms bolus instead of a continuous infusion. The isoproterenol is injected at the 30th minute of a 45-minute 60 degrees tilt test without returning the patient to the supine position. In this study, the isoproterenol bolus tilt test was found to be "positive" in 24 of 30 patients reporting unexplained syncope: 10 cases before the 30th minute (11.2 +/- 8.4 min) and 14 cases after administration of 5.1 +/- 1.9 micrograms of isoproterenol.
The beneficial effects of polynuclear eosinophils (PE) are well known. However, under certain circumstances, PE can be harmful. The heart is a prime target for PE toxicity which is due to release of basic proteins by eosinophils including major basic protein, cationic protein, and peroxidase. The most common manifestation of PE toxicity is chronic parietal endocarditis (CPE) which regroups two entities: Loeffler's fibroplastic endocarditis and Davies' endomyocardial fibrosis. Loeffler's fibroplastic endocarditis occurs mainly in temperate climates. Patients present high, persistent eosinophil levels similar to those observed in essential hypereosinophilic syndrome (EHS) or Chusid syndrome. Davies' endomyocardial fibrosis occurs in tropical countries where eosinophilic helminthiasis are endemic. The incidence of eosinophilic myocarditis (EM) is low but probably underestimated. EM can be observed in any case involving PE and has been described in many cases of drug-induced atopy, in Churg and Strauss syndrome, and in EHS. The most common cause of death is short-term occurrence of cardiogenic shock or dilated hypokinetic cardiomyopathy. Some patients have been successfully treated by early, intensive corticosteroid therapy and/or heart transplantation. The nosological classification of EM and CPE remains controversial. The two disorders may form a continuum with CPE as the second phase. Other authors have suggested that EM and CPE result from the action of PE on two distinct targets, i.e. endothelial cells for EM and myocytes for CPE. In the future, it may be possible to identify subjects with a predisposition to PE-induced heart disease by studying of genes coding for interleukins (IL-5, IL-4, IL-3) and GM-CSF in the 5q31-q33 region of chromosome 5.
This report describes three histologically documented cases of acute eosinophilic myocarditis. These three cases illustrate the different clinical and therapeutic outcomes of this disease which can range from full recovery under prolonged corticosteroid treatment to requirement for emergency heart transplantation or death due to intractable cardiac insufficiency. In absence of specific clinical or laboratory data, diagnosis must be established in vivo by endomyocardial biopsy demonstrating eosinophil-rich inflammatory infiltration and necrotic lesions. Rapid decision-making is necessary to allow early initiation of intensive corticosteroid treatment without which the most likely outcome is death. Clinicopathological and experimental evidence suggests that acute eosinophilic myocarditis is caused by the cytotoxic effects of granule components (mainly major basic protein) released by activated polynuclear eosinophils.
The authors report the case of a 50 year old man with pseudowanthoma elastica with a history of myocardial infarction and severe aortic regurgitation. Angiography showed multiple coronary artery aneurysms and aneurysmal dilatation of the aortic annulus. The outcome after triple coronary bypass surgery with aortic valve replacement in a valved Bentall conduit was favourable. Pseudoxanthoma elastica is a rare condition in which the prognosis depends on the degree of vascular involvement. In this context, coronary artery aneurysms and aneurysmal dilatation of the aorta are rare complications.
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Halofantrine is an antimalarial drug which is widely prescribed for the treatment of infections with chloroquine-resistant strains of Plasmodium falciparum. Chemically, it is a phenanthrene methanol, belonging to the aryl-amino-alcohol family. It has recently been recognized that this drug may induce rare but serious, cardiotoxic effects, including lengthening of the QTc interval, 'torsade de pointes' and induction of late ventricular potentials. These events are thought to be related to a quinidine-like action of the drug. In addition, severe haemolytic accidents have been reported, mimicking blackwater fever and indicating an immunological process. As a result of these side-effects, new guidelines for prescription and more cautious use of halofantrine, particularly as a stand-by treatment for febrile access among travellers, are required.
We report a case of fortuitously observed Castleman's disease. An mediastinal opacity was observed on the chest x-ray. At surgery, the apparently benign tumor was well individualized. Pathology reported Castleman's disease. Pathogenesis is unknown. Recent data on localized and more diffuse forms of this disease are presented. Diffuse forms occur more readily in immunodepressed patients.
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The incidence of cardiovascular events during travel is rising with the age of the population and number of traveling seniors. Cardiovascular events are the second most frequent reason for medical evacuation and the cause of 50% of deaths recorded during commercial air travel. In most cases the underlying disorder is coronary artery disease which is readily destabilized by stress and fatigue associated with travel. Inflight conditions that can cause problems include altitude-related hypoxia, pressurization, and cramped seating in most sections of the plane. Upon arrival the traveler is exposed to a variety of climatic, food, and environmental factors that can trigger manifestations of latent heart disease. Prophylactic drugs for tropical infectious disease (especially antimalarials of the quinidine group) should be used with caution due to possible adverse interaction with medications used to treat heart disease. A pre-travel examination is necessary to ascertain cardiovascular status and define simple preventive precautions.
Asymptomatic ventricular extrasystoles were discovered in 2 active sportsmen (32 and 33 years). The cardiology work-up rapidly led to the diagnosis of arrhythmogenic right ventricular dysplasia in one. In the other, the clinical presentation was similar and the initial diagnosis was ventricular extrasystole with a healthy heart. Four years later however, the subject was still asymptomatic but a second evaluation revealed arrhythmogenic right ventricular dysplasia. This delayed diagnosis emphasizes the importance of renewed noninvasive evaluation of patients with asymptomatic ventricular extrasystoles.
The authors report the case of a pulmonary arteriovenous fistula presenting with dyspnoea and cyanosis in a young adult. The malformation was situated on the proximal pulmonary vessels and was cured by surgical correction. The diagnostic value of the clinical signs and complementary investigations of this rare conditions, often detected during adulthood, is discussed. The functional tolerance of the condition is often variable. Oxygen desaturation of arterial blood indicates a right-to-left shunt. Pulmonary angiography enables visualisation of the lesions and guides surgical management. The prevalence of complications of this condition is not well known, but the potential severity is an argument for therapeutic intervention. Embolisation techniques are developing but there is a risk of a systemic embolism. Surgery is the reference for the treatment of proximal fistulae, its curative effect being immediate and definitive.
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