Influence de diagnostics alternatifs spécifiques sur la probabilité d'embolie pulmonaire

L'évaluation de la probabilité clinique est devenue un instrument indispensable dans le diagnostic de l'embolie pulmonaire. L'existence d'un diagnostic alternatif à l'embolie pulmonaire, et sa probabilité relative à celle-ci, constitue une variable importante du score de Wells, qui est un outil validé pour l'estimation de la probabilité clinique d'embolie pulmonaire. Toutefois, l'influence de la nature du diagnostic alternatif sur la probabilité clinique d'embolie pulmonaire n'a pas été étudiée à ce jour. Nous avons donc analysé rétrospectivement une cohorte de 965 patients consécutifs admis dans trois centres d'urgence européens pour suspicion d'embolie pulmonaire, pour lesquels la nature et la probabilité d'un diagnostic alternatif avaient été estimées avant toute investigation. Nous avons estimé la probabilité d'embolie pulmonaire pour chaque catégorie de diagnostic alternatif et l'avons comparée à un groupe de référence. Bien que la plupart des diagnostics évoqués diminuent significativement la probabilité d'embolie pulmonaire, aucun ne permet de l'exclure sans investigations supplémentaires

Normalization of left ventricular filling pressure after cardiac surgery for the Loeffler’s endocarditis: a case report

Background: Loeffler endocarditis is a rare restrictive cardiomyopathy, characterized by hypereosinophilia and fibrous thickening of the endocardium causing progressive onset of heart failure and appearance of thrombi on the walls of the heart chambers. Case summary: A 72-year-old man known for hypertension and dyslipidaemia consults for progressive dyspnoea up to New York Heart Association (NYHA) Classes 2-3 over 3 weeks. The biological balance sheet shows a high eosinophil level and an echocardiography shows a mild echodensity fixed to the left apex. After exclusion of a secondary cause of hypereosinophilia, diagnosis of endomyocardial fibrosis in the context of a hypereosinophilic syndrome (HES) is therefore retained. The patient's clinical presentation with cardiac involvement leads us to start a treatment with corticosteroids. The patient is then regularly followed every 6 months with an initially stable course without complications. Two years later, he develops progressive signs of heart failure. Transthoracic echocardiography shows a left ventricular (LV) dilatation with a normal ejection fraction, but decreased volume due to a large echodense mass in the apex, and moderate aortic regurgitation caused by myocardial infiltration. In view of this rapid evolution, resection of the LV mass with concomitant aortic valve replacement is performed. Pathology confirms eosinophilic infiltration. The clinical course is very good with a patient who remains stable with dyspnoea NYHA Classes 1-2, and echocardiography at 1 year shows a normalization of LV filling pressure. Discussion: HES represents a heterogeneous group of disorders characterized by overproduction of eosinophils. One of the major causes of mortality is associated cardiac involvement. Endocardial fibrosis and mural thrombosis are frequent cardiac findings. Echocardiography plays a crucial role in initial diagnosis of endomyocardial fibrosis, and for regular follow-up in order to adapt medical treatment and monitor haemodynamic evolution of the restrictive physiology and of valvular damage caused by the disease's evolution. This case also shows that surgery can normalize filling pressure and allow a clear improvement on the clinical condition even at the terminal fibrotic state.</p

Reproduction of chest pain by palpation: diagnostic accuracy in suspected pulmonary embolism

International audienc

Influence of specific alternative diagnoses on the probability of pulmonary embolism

The presence and likelihood of an alternative diagnosis to pulmonary embolism is an important variable of the Wells' prediction rule for establishing clinical probability. We assessed whether evoking specific alternative diagnoses would reduce the probability of pulmonary embolism enough to forego further testing. We retrospectively studied a cohort of 965 consecutive patients admitted for suspicion of pulmonary embolism at three medical centers in Europe in whom the presence of an alternative diagnosis at least as likely as pulmonary embolism was recorded before diagnostic testing. We divided the patients into 15 categories of alternative diagnoses evoked. We then assessed the prevalence of pulmonary embolism in each diagnostic category and compared it to the prevalence of pulmonary embolism in a reference group (patients with no alternative diagnosis or a diagnosis less likely than pulmonary embolism). The prevalence of pulmonary embolism in the reference group was 48%. The presence of an alternative diagnosis as or more likely strongly reduced the probability of pulmonary embolism (OR 0.15, 95% CI: 0.1-0.2, p < 0.01). In almost every diagnostic category, the prevalence of pulmonary embolism was much lower than in the reference group with an odds ratio below or near 0.2. Bronchopneumonia (OR 0.4, 95% CI 0.2 to 0.7) and cancer (OR 0.6, 95% CI 0.3 to 1.5) reduced the likelihood of pulmonary embolism to a lower extent. Evoking an alternative diagnosis at least as likely as pulmonary embolism reduces the probability of the disease, but this effect is never large enough to allow ruling it out without further testing, especially when bronchopneumonia or cancer are the alternative diagnoses considered

Surgical Treatment of Constrictive Pericarditis

Constrictive pericarditis is the final stage of a chronic inflammatory process characterized by fibrous thickening and calcification of the pericardium that impairs diastolic filling, reduces cardiac output, and ultimately leads to heart failure. Transthoracic echocardiography, computed tomography, and cardiac magnetic resonance imaging each can reveal severe diastolic dysfunction and increased pericardial thickness. Cardiac catheterization can help to confirm a diagnosis of diastolic dysfunction secondary to pericardial constriction, and to exclude restrictive cardiomyopathy. Early pericardiectomy with complete decortication (if technically feasible) provides good symptomatic relief and is the treatment of choice for constrictive pericarditis, before severe constriction and myocardial atrophy occur. We describe our surgical approach to constrictive pericarditis, summarize our results in 93 patients, and provide a brief overview of the literature