[Show abstract][Hide abstract] ABSTRACT: AIMS:
Define the impact of age at diagnosis on degenerative mitral regurgitation (MR) prognosis.
METHODS AND RESULTS:
The Mitral regurgitation International DAtabase (MIDA) is a multicentre registry of MR due to flail leaflets including 862 patients (65 ± 12 years) diagnosed by echocardiography. The 498 older patients (≥65 years at diagnosis) were compared with the 364 younger (<65) with regard to presentation and the outcome was compared with that expected in the general population. Older vs. younger patients had MR of similar severity and ventricular overload but presented with more MR consequences and incurred higher mortality [risk ratio (rr) 95% confidence interval (95% CI) 4.7 (2.5-10.0), P < 0.001] independently of co-morbidity. Compared with expected survival [relative risk (95% confidence interval)], excess mortality, non-significant in younger patients [1.1 (0.6-2.0), P = 0.65], was prominent in older patients [1.4 (1.2-1.7), P < 0.001]. Compared with expected, excess heart failure (HF) occurred in younger [9.3 (6.5-13.3), P < 0.0001) and in older patients [6.7 (5.6-8.1), P < 0.0001]. Excess atrial fibrillation (AF) was even higher in younger [6.9 (4.5-10.6), P < 0.0001] than in older patients [3.5 (2.6-4.7), P < 0.0001; P < 0.001 for comparison between age groups]. Subsequent excess mortality [rr (95% CI)] was associated with occurrence of HF and/or AF in both age groups [13.5 (7.4-24.6), P < 0.001]. Mitral surgery was associated with reduced long-term mortality in older patients and lower rate of HF in both the age groups (all P < 0.01).
Both older and younger patients incurred excess risk of complications. Older patients suffered excess mortality, AF, and HF, whereas younger incurred excess morbidity linked to subsequent long-term excess mortality. The excess risks of uncorrected degenerative MR should be considered in deliberating surgical management, which significantly reduced mortality in older patients and HF in younger patients.
European Heart Journal 09/2013; 34(33)::2600-9. · 14.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:Antibiotics, used for 60 years to promote weight gain in animals, have been linked to obesity in adults and in children when administered during early infancy. Lactobacillus reuteri has been linked to obesity and weight gain in children affected with Kwashiorkor using ready-to-use therapeutic food. In contrast, Escherichia coli has been linked with the absence of obesity. Both of these bacteria are resistant to vancomycin.Objectives and methods:We assessed vancomycin-associated weight and gut microbiota changes, and tested whether bacterial species previously linked with body mass index (BMI) predict weight gain at 1 year. All endocarditis patients treated with vancomycin or amoxicillin in our center were included from January 2008 to December 2010. Bacteroidetes, Firmicutes, Lactobacillus and Methanobrevibacter smithii were quantified using real-time PCR on samples obtained during the 4-6 weeks antibiotic regimen. L. reuteri, L. plantarum, L. rhamnosus, Bifidobacterium animalis and E. coli were quantified on stool samples obtained during the first week of antibiotics.Results:Of the193 patients included in the study, 102 were treated with vancomycin and 91 with amoxicillin. Vancomycin was associated with a 10% BMI increase (odds ratio (OR) 14.1; 95% confidence interval (CI; 1.03-194); P=0.047) and acquired obesity (4/41 versus 0/56, P=0.01). In patients treated with vancomycin, Firmicutes, Bacteroidetes and Lactobacillus increased, whereas M. smithii decreased (P<0.05). The absence of E. coli was an independent predictor of weight gain (OR=10.7; 95% CI (1.4-82.0); P=0.02). Strikingly, a patient with an 18% BMI increase showed a dramatic increase of L. reuteri but no increase of E. coli.Conclusion:The acquired obesity observed in patients treated with vancomycin may be related to a modulation of the gut microbiota rather than a direct antibiotic effect. L. reuteri, which is resistant to vancomycin and produces broad bacteriocins, may have an instrumental role in this effect.
[Show abstract][Hide abstract] ABSTRACT: La cardiomyopathie hypertrophique (CMH) est une affection d’origine génétique (transmission autosomique dominante) caractérisée
par une hypertrophie localisée ou diffuse du ventricule gauche (VG). La prévalence de cette affection est de 0,2 % et elle
représente la première cause de mort subite chez l’adulte jeune et le sportif. La place de l’IRM dans l’évaluation pronostique
de ces patients est double à la fois sur le diagnostic positif de l’affection et plus directement sur l’évaluation du risque
de mort subite lié à cette affection. Un dépistage précoce et de qualité de la CMH apparaît donc nécessaire afin de pouvoir
au mieux prévenir le risque de mort subite. Le diagnostic de CMH débutante est parfois délicat, surtout lorsque l’affection
est suspectée chez un sportif de bon niveau (⩾ 10 heures de sport par semaine). Le diagnostic différentiel entre l’hypertrophie
physiologique du sportif et la cardiomyopathie hypertrophique requiert des explorations spécifiques qui doivent inclure la
réalisation d’une IRM cardiaque. L’échocardiographie reste, évidemment, l’examen de référence et de première intention. Néanmoins,
l’IRM a l’avantage par rapport à l’échocardiographie de : 1) explorer l’ensemble des segments du VG y compris sa paroi latérale
et la zone apicale, 2) de permettre des mesures très précises de l’épaisseur télédiastolique, des volumes et de la masse ventriculaire
gauche, 3) de permettre la visualisation des zones de fibrose dans le myocarde. Le but de cette mise au point est : 1) d’exposer
le rôle de l’IRM dans le diagnostic positif des CMH, 2) de préciser le rôle de l’IRM et des séquences de rehaussement tardif
dans l’évaluation du risque de mort subite.
[Show abstract][Hide abstract] ABSTRACT: Pulmonary hypertension (PH) is defined as an increased mean pulmonary artery pressure (P(pa)) >25 mmHg at rest as assessed by right heart catheterisation (RHC). However, this technique is invasive and noninvasive alternatives are desirable for early diagnosis of PH. Although estimation of systolic pulmonary arterial pressure is easily obtained using Doppler echocardiography, cases of under- and over-estimations are not rare and direct measurement of P(pa) is not possible using this method. Therefore, echocardiography should be considered as a tool for assessment of the likelihood rather than the definite presence or absence of PH. Transthoracic echocardiography may be useful for noninvasive screening of patients at risk of PH. On the basis of an echocardiographic assessment, patients showing signs suggestive of PH can be referred for a confirmatory RHC. A number of variables measured during echocardiography reflect the morphological and functional consequences of PH and have prognostic value. The presence of pericardial effusion, reduced tricuspid annular plane excursion and right atrial enlargement are associated with a poorer prognosis. Echocardiography is also an important procedure for monitoring the response of patients to therapy, and is recommended 3-4 months after initiation of, or a change in, therapy. Echocardiographic assessment as part of a goal-oriented approach to therapy is essential for the effective management of PH patients.
European Respiratory Review 12/2010; 19(118):288-99.
[Show abstract][Hide abstract] ABSTRACT: To analyse characteristics and outcomes of infective endocarditis (IE) on bicuspid aortic valves (BAV) and to compare the risk of death according to the presence or absence of BAV.
5-year observational study.
Population of 856 patients with definite IE according to the Duke criteria from two tertiary centres (Amiens and Marseille, France).
310 consecutive patients with definite native aortic valve IE enrolled between 1991 and 2007.
Patients underwent transthoracic and transoesophageal echocardiography during hospitalisation. Surgery was performed on a case-by-case basis according to conventional guidelines.
In-hospital mortality and 5-year overall mortality.
Patients with BAV IE (n=50, 16%) were younger, had fewer comorbidities and a higher frequency of aortic perivalvular abscess (50%). Presence of BAV (OR 3.79 (1.97-7.28); p<0.001) was independently predictive of abscess formation. Early surgery was performed in 36 BAV patients (72%) with a peri-operative mortality of 8.3%, comparable to that of patients with tricuspid aortic valve IE (p=0.89). BAV was not independently predictive of in-hospital mortality (OR 0.89 (0.28-2.85); p=0.84) or 5-year survival (HR 0.71 (0.37-1.36); p=0.30). Age, comorbidities, heart failure, Staphylococcus aureus and uncontrolled infection were associated with increased 5-year mortality in BAV patients.
BAV is frequent in adults with native aortic valve IE. Patients with BAV IE incur high risk of abscess formation and require early surgery in almost three-quarters of cases. IE is a severe complication in the setting of BAV and warrants prompt diagnosis and treatment.
[Show abstract][Hide abstract] ABSTRACT: Pulmonary arterial hypertension (PAH) is a progressive, fatal disease. We studied 674 consecutive adult patients who were prospectively enrolled in the French PAH registry (121 incident and 553 prevalent cases). Two survival analyses were performed. First, the cohort of 674 patients was followed for 3 yrs after study entry and survival rates described. Then, we focused on the subset with incident idiopathic, familial and anorexigen-associated PAH (n = 56) combined with prevalent patients who were diagnosed <3 yrs prior to study entry (n = 134). In the cohort of 674 patients, 1-, 2-, and 3-yr survival rates were 87% (95% CI 84-90), 76% (95% CI 73-80), and 67% (95% CI 63-71), respectively. In prevalent idiopathic, familial and anorexigen-associated PAH, 1-, 2-, and 3-yr survival rates were higher than in incident patients (p = 0.037). In the combined cohort of patients with idiopathic, familial and anorexigen-associated PAH, multivariable analysis showed that survival could be estimated by means of a novel risk-prediction equation using patient sex, 6-min walk distance, and cardiac output at diagnosis. This study highlights survivor bias in prevalent cohorts of PAH patients. Survival of idiopathic, familial and anorexigen-associated PAH can be characterised by means of a novel risk-prediction equation using patients' characteristics at diagnosis.
European Respiratory Journal 09/2010; 36(3):549-55. · 6.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Infective endocarditis (IE) remains in 2008 a serious disease that requires special care. The diagnosis is sometimes difficult and the management depends on the circumstances of the diagnosis and the type of clinical ward in which the patient is hospitalized. Diagnostic scores have been proposed to remedy this heterogeneity and allow the prompt start of simple antibiotic protocols.
We have established a multidisciplinary management of endocarditis in the tertiary care referral center of Marseille in April 1994. It is based on the systematic prescription at patient's admission of a microbiological diagnostic kit that limits the number of blood cultures performed and enables through serologic testing to identify major bacterial etiologies (Coxiella burnetii, Bartonella spp.) in blood culture negative endocarditis. The use of molecular tools in routine for blood and explanted valves also reduced the number of IE without etiology.
The severity of the disease prompted us to establish a score to identify at the time of admission patients at high risk of IE to expedite the diagnostic process or start empirical antibiotic therapy.
The fact that antimicrobial therapy often varies from center to center and even from one clinician to another, led us to define a management of IE based on the strict application of simple antibiotic protocols, precise surgical guidance, and medical monitoring for one year of patients.
Our multidiciplinary and standardized management of endocarditis patients enabled us to reduce the proportion of endocarditis without identified cause to 7%, and to significantly reduce the overall mortality.
[Show abstract][Hide abstract] ABSTRACT: The SeptiFast test (Roche Diagnostics) is a new commercial molecular technique that has emerged for the detection of bacteria in blood. We compared in this study the sensitivity of blood culture to a commercially available broad-range real-time polymerase chain reaction (PCR) assay for the detection in blood of 19 bacterial species and six fungal species (SeptiFast test, Roche Diagnostics) in 63 patients with infectious endocarditis (IE). The SeptiFast test is not more sensitive for organisms such as Streptococci, Enterococci, and Staphylococcus aureus (11/29 versus 12/29 for blood culture). It has detected less commonly coagulase-negative Staphylococci (0/15 versus 3/15, P = 0.2) and significantly fewer other microorganisms (0/6 versus 4/6, P = 0.03). However, bacteria were detected from three IE treated by antibiotics, with blood culture negative on admission. The SeptiFast test may be useful in cases of IE in patients treated with antibiotics before admission.
European Journal of Clinical Microbiology 01/2009; 28(6):569-73. · 3.02 Impact Factor