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Cardiac tamponade as the initial presentation of hypothyroidism is extremely rare. We report the case of a 48-year-old man admitted for acute respiratory distress, with cardiac ultrasound showing compressive pericardial effusion. Percutaneous pericardiocentesis was performed leading to a rapid clinical improvement. Laboratory tests confirmed severe hypothyroidism related to Hashimoto’s disease. Despite hormone replacement therapy, pericardial effusion recurred after 3 weeks, requiring surgical drainage. Pericardial histology highlighted slight chronic fibrous pericarditis. The cardiac ultrasound scan performed 4 months later showed a well-tolerated chronic pericardial effusion. In conclusion, hypothyroidism should be suspected in case of cardiac tamponade especially in the absence of tachycardia, or in winter when myxoedema is prone to decompensation. Prognosis is generally good under hormone replacement therapy but ultrasound monitoring should be carried out at least until euthyroidism is achieved.

Multi-slice computed tomography (MSCT) has proven in several studies to have a high diagnostic accuracy for the detection or exclusion of coronary artery disease. A major concern with coronary MSCT, however, is the associated radiation exposure of patients. Recent studies suggest that use of a 64-slice scanner is associated with a non-negligible lifetime attributable risk of cancer. Several strategies can be used to reduce patient exposure in coronary MSCT. The purpose of this multicenter study was to investigate the effects of the adjustment of tube voltage and current on radiation dose and image interpretability. MSCT with retrospective ECG gating was performed in 315 patients. The dose-length product (DLP) in the patients enrolled with the dose reduction protocol resulted in a 36% overall reduction in the mean radiation dose (911 ± 289 mGy.cm) compared with the standard protocol (1427 ± 226 mGy.cm, p

Quantification of right ventricular (RV) function is clinically relevant for the risk stratification and follow-up of patients with a wide spectrum of disease. This can be achieved with electrocardiography-gated blood pool single photon emission computed tomography (GBPS). We aimed to evaluate the accuracy of the completely automatic QBS GBPS processing software as compared with equilibrium planar radionuclide angiography (RNA) and with a GBPS manual segmentation method (GBPS35%) for the measurement of global RV ejection fraction (EF), taking the first-pass RNA (FP-RNA) as the gold standard. In parallel, we compared the RVEF, RV end-diastolic volume (EDV), and RV end-systolic volume (ESV) provided by QBS and GBPS35%. The population included 85 patients with chronic post-embolic pulmonary hypertension. Twenty-one patients were excluded because of unsuccessful FP-RNA. Intraobserver and interobserver RVEF, RVEDV, and RVESV reproducibilities encountered with planar RNA, QBS, and GBPS35% were similar and compared favorably with those calculated with FP-RNA for RVEF. Mean RVEF was different between all methods. RVEF calculated with FP-RNA was better correlated to QBS (r = 0.68) and GBPS35% (r = 0.70) than to planar RNA (r = 0.59). RVEDV and RVESV with QBS were lower than with GBPS35%, by 29% ± 14% and 36% ± 13%, respectively. RVEDV and RVESV with QBS were highly correlated to corresponding GBPS35%values: r = 0.88 and r = 0.91, respectively. As opposed to FP-RNA, GBPS is highly successful for the quantification of RV function. Both QBS and GBPS35% provide RVEF values similarly well correlated to FP-RNA and performed better than planar RNA. RVEF, RVEDV, and RVESV provided by QBS and GBPS35% are highly correlated. All of these RV functional measurements require further validation versus a better gold standard before their accuracy can be established.

Study objective: We hypothesized that a dynamic leftventricular (LV) evaluation during a loading challenge might enhancediagnostic capabilities of routine transesophageal echocardiography incritically ill patients and selection of therapeutic options againstcirculatory failure, particularly the choice between volume expansionand vasoactive agent infusion. Design: Prospectiveclinical study in a group of 26 patients requiring hemodynamic supportby vasoactive infusion because of low systemic arterial pressure( Setting: University hospital ICU. Patients: Patients required respiratory support for anepisode of acute respiratory failure of various causes or for anepisode of coma. They were studied by transesophageal echocardiographyduring mechanical ventilation in the controlled mode, before and duringa loading challenge made using the legs compartment of medicalantishock trousers inflated at 80 mm Hg. Measurements: A short-axis view of the left ventricle was obtained by a transgastricapproach, and end-diastolic and end-systolic areas were measured. LVstroke area (LVSA) and LV fractional area contraction (LVFAC) werecalculated. Results: Changes in LVechocardiographic measurements permitted separation of the patientsinto two groups. In nine patients (group 1), LVSA, used as an index ofstroke output, was significantly increased during the challenge, together with a significant increase in LV end-diastolic area, suggesting preload improvement by the challenge. Conversely, in 17patients (group 2), LVSA was significantly reduced by the challenge, together with a significant decrease in LVFAC, suggesting a negativeeffect of increased afterload by the challenge. Conclusion: Study of the changes in LV dimensions duringloading challenge in hemodynamically unstable patients was used toevaluate the balance between the adequacy of preload and the ability ofthe heart to pump against an increased load, and might thus guidehemodynamic support.

Study objective To investigate the rate of recovery from septic shock in patients with suspected left ventricular (LV) preload deficiency and LV systolic dysfunction. Design A monitoring period was defined by the need for inotropic/vasopressor support, and LV function was assessed daily during this period by bedside two-dimensional echocardiography (2D-ECHO). Setting University hospital ICU. Patients During a 5-year period, 90 patients with an episode of septic shock (60% with gram-positive bacteria as the causative agent) were consecutively enrolled in the study (mean age, 55 ± 18 years). Standard volume resuscitation combined with inotropic/vasopressor support was used to maintain systolic arterial pressure > 90 mm Hg. All patients received mechanical ventilation because of associated respiratory failure. The average duration of hemodynamic support was 4.4 ± 1.6 days. Thirty-four patients were weaned from hemodynamic support during the monitoring period and ultimately recovered (group I). Twenty-eight patients died from refractory circulatory failure during the monitoring period, and 28 died later from ARDS or multiple organ dysfunction syndrome, leading to a 62% overall mortality rate (group II). Methods Daily bedside LV volumes and ejection fraction (LVEF) were recorded using 2D-ECHO. Data obtained at the start (day 1 and day 2) and end of the monitoring period (day n ) were compared. Results LV end-diastolic volume was within the normal range of our laboratory values in all patients, but was initially smaller in group II than in group I, and remained so despite fluid loading. LVEF was significantly depressed in all patients, resulting in severe reduction in LV stroke volume (LVSV), which was initially more marked in group I. In group I patients, LVEF significantly improved during the monitoring period, resulting in an increase in LVSV. Conclusion 2D-ECHO changes during hemodynamic support in 90 septic patients confirmed defective LV preload with a propensity to worsen despite fluid loading in nonsurvivors (62% in the present study). Our results are also in agreement with previous studies reporting depressed LV systolic function at the initial phase of septic shock. Since LV dysfunction was more marked in patients who recovered, we suggest that the exact significance of this finding should be reevaluated.

A 76-year-old man with a history of two-vessel coronary artery bypass grafting was admitted with recurrent angina. The proximal anastomosis of the left anterior descending (LAD) bypass grafting was directly stented with a bare-metal stent 2 years before. Conventional angiography was performed, but selective LAD bypass catheterization failed. In this …

In the literature, the foreign bodies described in the cardiac cavities are medical devices such as embolization of a catheter or a fragment from the catheter.1,2 We report a case of an unusual finding in the heart. A 42-year-old woman was admitted to the cardiac intensive care unit because of syncope associated with atypical chest pain and palpitations. She had no significant medical history with no previous cardiac, venous, or artery catheterization. She described a lipothymia event a few weeks ago. Her physical examination was unremarkable except for a tattoo on the left parasternal skin done 3 years before. Her electrocardiogram revealed multiple ventricular premature beats. Treadmill stress test showed a sustained right ventricular tachycardia without ST depression. Transthoracic echocardiography revealed a linear hyperechogenic image in the right ventricle …

Background— This large, prospective, multicentric study was performed to analyze the distribution of tricuspid regurgitation velocity (TRV) values during exercise and hypoxia in relatives of patients with idiopathic and familial pulmonary arterial hypertension (PAH) and in healthy control subjects. We tested the hypothesis that relatives of idiopathic/familial PAH patients display an enhanced frequency of hypertensive TRV response to stress and that this response is associated with mutations in the bone morphogenetic protein receptor II ( BMPR2 ) gene. Methods and Results— TRV was estimated by Doppler echocardiography during supine bicycle exercise in normoxia and during 120 minutes of normobaric hypoxia (F io 2 =12%; ≈4500 m) in 291 relatives of 109 PAH patients and in 191 age-matched control subjects. Mean maximal TRVs were significantly higher in PAH relatives during both exercise and hypoxia. During exercise, 10% of control subjects but 31.6% of relatives ( P P =0.0029). Among control subjects, TRV at rest was not related to age, sex, body mass index, systemic blood pressure, smoking status, or heart rate. Within kindreds identified as harboring deleterious mutations of the BMPR2 gene, a hypertensive TRV response occurred significantly more often compared with those without detected mutations. Conclusions— Pulmonary hypertensive response to exercise and hypoxia in idiopathic/familial PAH relatives appears as a genetic trait with familial clustering, being correlated to but not caused by a BMPR2 mutation. The suitability of this trait to predict manifest PAH development should be addressed in long-term follow-up studies.

Clinical studies have shown the importance of endothelin as a pathogenic mediator in pulmonary arterial hypertension (PAH). We describe the effects of bosentan, an oral dual endothelin receptor antagonist, in patients with PAH associated with human immunodeficiency virus (HIV) infection. In this prospective study, 16 patients with PAH associated with HIV infection in stable condition received bosentan for 16 weeks. Efficacy endpoints included exercise capacity, cardiopulmonary hemodynamics, Doppler echocardiography, New York Heart Association functional class, and quality of life (SF-36 and EQ-5D). Safety was assessed by laboratory tests, vital signs, and adverse events. Improvements were observed from baseline to Week 16 in all efficacy parameters: 6-minute walk distance (+91 +/- 60 m, p0.001), New York Heart Association class (14 patients improved), hemodynamics (cardiac index: +0.9 +/- 0.7 L/minute/m(2), p0.001), Doppler echocardiographic variables, and quality of life. During the study, no patient died and none required epoprostenol treatment. Hepatic tolerability was similar to that reported in patients with PAH. Bosentan had no negative impact on control of HIV infection. Although limited by uncontrolled design, small sample size and short duration, this study suggests that bosentan may benefit patients with PAH associated with HIV infection, and that endothelin is an important pathogenic mediator in this disease.

It is unknown whether the use of ordered-subsets expectation maximization (OSEM) and depth-dependent resolution recovery (RR) will increase the accuracy of (201)Tl electrocardiogram-gated SPECT (GSPECT) for the measurement of global left ventricular (LV) function.Fifty-six patients having both rest (201)Tl GSPECT and planar equilibrium radionuclide angiography (planar(RNA)) on the same day were studied. Twenty-nine patients also had LV conventional contrast angiography (Rx). LV ejection fraction (LVEF), end-diastolic volume (EDV), and end-systolic volume (ESV) were calculated with the quantitative gated SPECT software (QGS) using 4 different processing methods: filtered backprojection (FBP), OSEM, RR + FBP, and RR + OSEM. LVEF calculated with planar(RNA) and LV EDV and ESV calculated with Rx were considered gold standards. LVEF and volumes provided with the GSPECT methods were compared with the gold standard methods.LVEF calculated with GSPECT methods (FBP, OSEM, RR + FBP, and RR + OSEM) were similar (not statistically significant) and correlated well with planar(RNA). On Bland-Altman analysis, the mean +/- SD of absolute difference in LVEF with GSPECT FBP, OSEM, RR + FBP, and RR + OSEM methods versus planar(RNA) were similar, with relatively large limits of agreement. LV volumes calculated with the 4 GSPECT methods were significantly lower but correlated well with Rx LV volumes. LV volumes calculated with FBP and OSEM were lower than those calculated with RR + FBP and RR + OSEM (P0.01). On Bland-Altman analysis, the mean +/- SD of absolute difference in LV volumes with FBP, OSEM, RR + FBP, and RR + OSEM versus Rx was, respectively, 56 +/- 45 mL (P0.01 vs. the other 3 methods), 57 +/- 45 mL (P0.01 vs. the other 3 methods), 43 +/- 48 mL, and 46 +/- 47 mL, with correspondingly large limits of agreement. The variance of random error did not differ between FBP, OSEM, RR + FBP, and RR + OSEM for either LVEF or volumes.OSEM and FBP presented similar accuracy for LVEF and volume measured with the QGS software. Their combination with depth-dependent RR provided similar LVEF but more accurate LV volumes.

We identified eight patients (six women and two men) who had pulmonary infiltrates during treatment with minocycline hydrochloride between 1989 and 1992 in French referral centers for drug-induced pulmonary diseases. Clinical files, chest roentgenograms, computed tomographic scans, pulmonary function, and bronchoalveolar lavage data were reviewed. Minocycline treatment was given for acne (n=4), genital infection (n=3), and Lyme disease (n=1). The duration of treatment averaged 13±5 days (mean±SE); the total dose, 2060±540 mg. Patients presented with dyspnea (n=8), fever (n=7), dry cough (n=5), hemoptysis (n=1), chest pain (n=2), fatigue (n=3), and rash (n=3). Chest roentgenograms showed bilateral infiltrates in all cases. Pulmonary function was measured in five patients; four had airflow obstruction and two had mild restriction. Blood gas tests demonstrated hypoxemia in seven patients (58±3 mm Hg). Seven patients had blood eosinophilia (1.76±0.2×10 9 /L). Bronchoalveolar lavage (performed in seven patients) showed an increased proportion of eosinophils (0.30±0.07). The CD4 + / CD8 + ratio was determined in four cases and was low in three. Transbronchial lung biopsy, performed in two patients, showed interstitial pneumonitis in both patients, with marked infiltration by eosinophils in one patient. The outcome was favorable in all patients. Because of severe symptoms, steroid therapy was required in three patients. Rechallenge was not attempted. We conclude that minocycline can induce the syndrome of pulmonary infiltrates and eosinophilia, that presenting symptoms may be severe and may culminate in transient respiratory failure, and that the disease has a favorable prognosis. (Arch Intern Med. 1994;154:1633-1640)

Objectives The purpose of this study was to investigate the effects of bosentan (125 or 250 mg twice daily) on echocardiographic and Doppler variables in 85 patients with World Health Organization class III or IV pulmonary arterial hypertension (PAH). Background Bosentan, an orally active dual endothelin-receptor antagonist, improves symptoms, exercise capacity, and hemodynamics in patients with PAH. Methods Patients had primary pulmonary hypertension (84%) or PAH associated with connective tissue disease. Of these, 29 patients received placebo and 56 received bosentan (1:2 randomization). Six-minute walk tests and echocardiograms were performed at baseline and after 16 weeks of treatment. Results Baseline characteristics were similar in the placebo and bosentan groups, and echocardiographic and Doppler findings were consistent with marked abnormalities of right ventricular (RV) and left ventricular (LV) structure and function that were due to PAH. The treatment effect on 6-min walking distance was 37 m in favor of bosentan (p = 0.036). Treatment effects of bosentan compared with placebo on other parameters were as follows: Doppler-derived cardiac index = +0.4 l/min/m 2 (p = 0.007), LV early diastolic filling velocity = +10.5 cm/s (p = 0.003), LV end-diastolic area = +4.2 cm 2 (p = 0.003), LV systolic eccentricity index = −0.12 (p = 0.047), RV end-systolic area = −2.3 cm 2 (p = 0.057), RV:LV diastolic areas ratio = −0.64 (p = 0.007), Doppler RV index = −0.06 (p = 0.03), and percentage of patients with an improvement in pericardial effusion score = 17% (p = 0.05). Conclusions Bosentan improves RV systolic function and LV early diastolic filling and leads to a decrease in RV dilation and an increase in LV size in patients with PAH.