BACKGROUND: Infective endocarditis (IE) is associated with a high mortality rate, related in part to neurological complications. Studies suggest that valvular surgery should be performed early when indicated, but is often delayed by the presence of neurological complications.
OBJECTIVE: To assess the effect of delaying surgery in patients with IE and neurological complications and to identify factors predictive of death.
METHODS: In a prospective, single-centre study in a referral centre for IE, all patients with IE underwent systematic screening for neurological complications. The primary outcome was 6-month death. In patients presenting with neurological complications, the prognosis according to surgical status was analysed and a Cox regression model used to identify variables predictive of death.
RESULTS: Between April 2014 and January 2018, 351 patients with a definite diagnosis of left-sided IE were included. Ninety-four patients (26.8%) presented with at least one neurological complication. Fifty-nine patients (17.7%) died during 6-month follow-up. Six-month mortality rates did not differ significantly between patients with and without neurological complications (P=0.60). Forty patients had a temporary surgical contraindication because of neurological complications. During the period of surgical contraindication, seven of these patients (17.5%) died, six (15.0%) presented a new embolic event, and 12 (30.0%) presented cardiac or septic deterioration. In multivariable analysis, predictive factors of death in patients presenting with neurological complications were temporary surgical contraindication (hazard ratio 7.36, 95% confidence interval 1.61-33.67; P=0.010) and presence of a mechanical prosthetic valve (hazard ratio 16.40, 95% confidence interval 2.22-121.17; P=0.006).
CONCLUSIONS: Patients with a temporary surgical contraindication due to neurological complications had a higher risk of death and frequent major complications while waiting for surgery. When indicated, the decision to postpone surgery in the early phase should be weighed against the risk of infectious or cardiac deterioration.

BACKGROUND: 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) has recently been added as a major criterion in the European Society of Cardiology (ESC) 2015 infective endocarditis guidelines. PET/CT is currently used in patients with suspected prosthetic valve and cardiac device-related endocarditis. However, the value of the ESC classification and the clinical impact of PET findings are unknown in patients with native valve endocarditis (NVE).
OBJECTIVE: Our aims were: to assess the value of the ESC criteria (including PET/CT) in NVE; to determine the usefulness of PET/CT concerning embolic detection; and to describe a new PET/CT feature (diffuse splenic uptake).
METHODS: Between 2012 and 2017, 75 patients with suspected NVE were included prospectively, after exclusion of patients with uninterpretable or unfeasible PET/CT. Using gold standard expert consensus, 63 cases of infective endocarditis were confirmed and 12 were rejected.
RESULTS: Significant valvular uptake was observed in 11 of 63 patients with definite NVE and in no patients who had the diagnosis of infective endocarditis rejected (sensitivity 17.5%, specificity 100%). Among the 63 patients with NVE, a peripheral embolism or mycotic aneurysm was observed in 20 (31.7%) cases. Application of the ESC criteria increased Duke criteria sensitivity from 63.5% to 69.8% (P<0.001), without a change in specificity. Diffuse splenic uptake was observed in 39 (52.0%) patients, including 37 (58.7%) with a final diagnosis of NVE (specificity 83.3%).
CONCLUSIONS: 18F-FDG PET/CT has poor sensitivity but high specificity in the diagnosis of NVE. The usefulness of 18F-FDG PET/CT is high for embolic detection. Diffuse splenic uptake represents a possible new diagnostic criterion for NVE.

First-line treatment of prolactinoma is usually medical, based on dopamine agonists receptors, mainly cabergoline. The classical side-effects of cabergoline (low blood pressure and nausea) have been well known since it was first introduced. Other side-effects, however, are more controversial or simply less frequent, but need to be considered during monitoring. This review will focus on these side-effects: cardiac valvular fibrosis, pleural, pericardial and retroperitoneal fibrosis, addictive/compulsive behaviors, and risks secondary to significantly decreased tumor volume. We will also describe how such side-effects should be monitored and managed. In our opinion, the low prevalence of these side-effects should not cast doubt on the role of cabergoline in the therapeutic algorithm of prolactinoma.

Cardiogenic shock is a critical clinical situation, requiring rapid diagnosis, aetiological assessment and immediate initiation of therapy. In industrialized countries, aortic stenosis is the most frequent left-sided valvulopathy, followed by mitral regurgitation, aortic regurgitation and mitral stenosis. Severe valvulopathies leading to cardiogenic shock are not rare conditions, but few data are available on their optimal management. Therapeutic options for such critical conditions include inotropic agents, mechanical support (when feasible) and rapid valvular intervention. Although surgery remains the gold-standard treatment for severe valvular disease, mortality is frequently prohibitive in the setting of cardiogenic shock, necessitating consideration of alternative therapies. Percutaneous management of valvulopathies has emerged as an alternative treatment for patients deemed at high surgical risk in a stable condition. Although few published data are available, catheter-based interventions may be feasible in the cardiogenic shock setting. This review offers an overview of different valvulopathies in the cardiogenic shock setting, and summarizes the different therapeutic options currently available in such critical situations.

OBJECTIVE: The authors report the results of a study whose aim was to study ischemic stroke on atrial fibrillation associated with valvular rheumatic disease.
METHODS: The study was retrospective and descriptive covering a period of 5 years in the cardiology department of the Point G hospital, based off of in-patient records.
RESULTS: Twelve cases meeting the criteria were selected among a total of 1229 stroke admissions, or a prevalence of stroke and rheumatic valvular atrial fibrillation of 0.97%.
The sex ratio was equal to 1 with an average age 36 years ±2 where the youngest and oldest patients were 24 and 48 years old. The most common medical antecedents were rheumatic valvular heart disease and throat angina. The cardiological clinical aspect was dominated by an irregular beat and in neurological terms aphasia and right hemiplegia dominated 1/3 of cases. The atrial fibrillation was the constant electric signal with a dominant mitral valve impairment as observed via Doppler echocardiography. The cerebral scanner showed that the ischemia was constant.
CONCLUSIONS: The occurrence of Ischemic strokes on the atrial fibrillation rheumatic valve is a combination of a significant frequency. Its management is complex, prevention remains the only effective measure.
UNASSIGNED: Les auteurs rapportent les résultats d\'un travail dont le but était d\'étudier l\'accident vasculaire cérébral (AVC) ischémique sur fibrillation auriculaire (FA) liée à une valvulopathie rhumatismale.
UNASSIGNED: L\'étude était rétrospective et descriptive d\'une durée de 5 ans réalisée dans le service de Cardiologie de l\'Hôpital du Point G, sur la base des dossiers des malades hospitalisés.
UNASSIGNED: Douze cas répondant aux critères ont été recruté parmi un total de 1229 AVC hospitalisés soit une prévalence des accidents vasculaires cérébraux sur fibrillation atriale valvulaire rhumatismale de 0,97%.
Le sex-ratio était égal à 1 avec un âge moyen à 36 ans±2 ans et des extrêmes à 24 et à 48 ans. Les principaux antécédents médicaux étaient la valvulopathie rhumatismale et l\'angine de gorge. L\'aspect clinique cardiologique était dominé par le rythme irrégulier et sur le plan neurologique l\'aphasie et l\'hémiplégie droite dominaient dans le 1/3 des cas. La FA était le signe électrique constant avec une atteinte valvulaire mitrale dominante à l\'échocardiographie Doppler. Au scanner cérébral l\'ischémie était constante.
CONCLUSIONS: L\'AVC ischémique sur la FA valvulaire rhumatismale est une association d\'une fréquence non négligeable. Sa prise en charge étant complexe, la prévention reste la seule mesure efficace.

Oral health is of particular importance in patients with heart valve diseases because of the risk of infective endocarditis. Recommendations for antibiotic prophylaxis before dental procedures have been restricted, but the modalities of oral evaluation and dental care are not detailed in guidelines. Therefore, a multidisciplinary working group reviewed the literature to propose detailed approaches for the evaluation and management of buccodental status in patients with valvular disease. Simple questions asked by a non-dental specialist may draw attention to buccodental diseases. Besides clinical examination, recent imaging techniques are highly sensitive for the detection of inflammatory bone destruction directly related to oral or dental infection foci. The management of buccodental disease before cardiac valvular surgery should be adapted to the timing of the intervention. Simple therapeutic principles can be applied even before urgent intervention. Restorative dentistry and endodontic and periodontal therapy can be performed before elective valvular intervention and during the follow-up of patients at high risk of endocarditis. The detection and treatment of buccodental foci of infection should follow specific rules in patients who present with acute endocarditis. Implant placement is no longer contraindicated in patients at intermediate risk of endocarditis, and can also be performed in selected high-risk patients. The decision for implant placement should follow an analysis of general and local factors increasing the risk of implant failure. The surgical and prosthetic procedures should be performed in optimal safety conditions. It is therefore now possible to safely decrease the number of contraindicated dental procedures in patients at risk of endocarditis.

OBJECTIVE: Management of macroprolactinomas has dramatically changed in recent decades, from surgical to medical treatment as first-line therapy, with the development of dopamine agonists (DA). But few data exist on the long-term outcome of these patients.
METHODS: Retrospective descriptive multicenter study of patients with macroprolactinoma followed for at least 5 years between 1973 and 2008 at the University Hospitals of Strasbourg and Marseille.
RESULTS: Forty-eight patients were included with 27 men, hypopituitarism in 33.3% of all patients and mean serum prolactin (PRL) level at diagnosis 2218.2±4154.7μg/L. Among the patients, 58.3% received medical treatment, 25% had additional surgery and 12.5% surgery and radiotherapy. The mean follow-up duration was 196±100 months. At the end of follow-up, 10 patients (20.8%) were cured (i.e. normal PRL level and normal imaging, no symptoms and withdrawal of DA≥1 year), 33 (68.8%) were controlled (i.e. normal PRL level, normal or abnormal imaging, no symptoms, DA in progress) and 5 (10.4%) were uncontrolled. Uncontrolled patients had significant higher baseline PRL level (P=0.0412) and cabergoline cumulative dose (P=0.0065) compared to the controlled group. There was no increase in frequency of hypopituitarism. Clinically significant valvular heart disease was found in 2 patients but screening was not systematic.
CONCLUSIONS: Macroprolactinoma is currently most often a chronic disease controlled with DA. However, uncertainty about the adverse effects associated with high cumulative doses and the lack of data on the prognosis at very long-term should incite to revisit current strategies, including the role of surgery combined to medical treatment.

The finding of a systolic heart murmur is common in medical military practice. Albeit often benign among young healthy adults, it can reveal a valvular or a cardiac disease, which could worsen during workout or expose to risk of a sudden death. This study aims to evaluate the diagnostic efficiency of the military general practitioner when discovering a systolic murmur among young asymptomatic patients.
METHODS: During one year, this study involved all the general practitioners of the medical military centres of Brittany and the cardiologists of the military hospital in Brest. It prospectively enrolled a cohort of all military asymptomatic patients under 40, without any underlying known heart condition. Military general practitioners listed, thanks to an anonymous form, the main features of the systolic murmur and of the ECG and proposed an auscultatory diagnosis: innocent or organic murmur. Then cardiologists did the same and finally performed a transthoracic echocardiography giving the diagnosis.
RESULTS: Fifty-eight patients were referred, 5 not meeting the inclusion criteria. Of the 53 patients included, military general practitioners found 46 innocent murmurs and 7 organic ones. Cardiologists found 51 innocent murmurs and 2 organic. Transthoracic echocardiography just took on one organic murmur (linked with a bicuspid aortic valve), spotted by the specialist, though judged innocent by the general practitioner.
CONCLUSIONS: Most of innocent murmurs diagnosed by general practitioners (45/46) were confirmed. Regarding the seven organic murmurs, the main selected criteria (intensity over 3, orthostatic persistence, diffuse irradiation) are mostly in accordance with the literature, proving right medical instincts. Authors propose a practical management of systolic murmurs among asymptomatic young patients.
CONCLUSIONS: Military general practitioners seem to master symptoms of organic murmur. This assessment argues for a promotion of a holistic clinical examination, which will help not only to rationalize the use of transthoracic echocardiography in economic terms but also to value the medical expertise.

Atrial fibrillation (AF) confers a substantial risk of stroke. Recent trials comparing vitamin K antagonists (VKAs) with non-vitamin K antagonist oral anticoagulants (NOACs) in AF were performed among patients with so-called \"non-valvular\" AF. The distinction between \"valvular\" and \"non-valvular\" AF remains a matter of debate. Currently, \"valvular AF\" refers to patients with mitral stenosis or artificial heart valves (and valve repair in North American guidelines only), and should be treated with VKAs. Valvular heart diseases, such as mitral regurgitation, aortic stenosis (AS) and aortic insufficiency, do not result in conditions of low flow in the left atrium, and do not apparently increase the risk of thromboembolism brought by AF. Post-hoc analyses suggest that these conditions probably do not make the thromboembolic risk less responsive to NOACs compared with most forms of \"non-valvular\" AF. The pathogenesis of thrombosis is probably different for blood coming into contact with a mechanical prosthetic valve compared with what occurs in most other forms of AF. This may explain the results of the only trial performed with a NOAC in patients with a mechanical prosthetic valve (only a few of whom had AF), where warfarin was more effective and safer than dabigatran. By contrast, AF in the presence of a bioprosthetic heart valve or after valve repair appears to have a risk of thromboembolism that is not markedly different from other forms of \"non-valvular\" AF. Obviously, we should no longer consider the classification of AF as \"valvular\" (or not) for the purpose of defining the aetiology of the arrhythmia, but for the determination of a different risk of thromboembolic events and the need for a specific antithrombotic strategy. As long as there is no better new term or widely accepted definition, \"valvular AF\" refers to patients with mitral stenosis or artificial heart valves. Patients with \"non-valvular AF\" may have other types of valvular heart disease. One should emphasize that \"non-valvular AF\" does not exclude patients with some types of valvular heart disease from therapy with NOACs.

Patients with valvular heart disease or with a prosthetic heart valve replacement are seen with increasing frequency in clinical practice. The medical care and evaluation of patients with valvular heart disease before valve surgery, but also the post-operative treatment is complex and managed by general practitioners, cardiologists and cardiac surgeons. In this mini-review we will first discuss the preoperative assessment of the two most common valvulopathies, aortic stenosis and mitral regurgitation. Then we will discuss the post-operative care, which includes the management of anticoagulation, serial follow up and as well as the diagnostic assessment of complications such as thromboembolism, hemolysis, endocarditis and valve dysfunction.
Patienten mit Herzklappenvitien oder nach Herzklappenersatz stellen eine in der Praxistätigkeit wachsende Patientengruppe dar. Die Betreuung und Abklärung von Patienten mit Herzklappenvitien vor Klappenoperationen, aber auch die postoperative Nachsorge ist komplex und erfolgt interdisziplinär durch Allgemeinpraktiker, Kardiologen und Herzchirurgen. In der vorliegenden Mini-Review befassen wir uns zunächst mit den präoperativen Abklärungen bei den zwei häufigsten Herzklappenvitien, der Aortenstenose und der Mitralinsuffizienz. Anschliessend besprechen wir die postoperative Nachsorge, die eine Kontrolle der oralen Antikoagulation sowie die Erfassung und korrekte Abklärung von Komplikationen wie Thromboembolie, Hämolyse, Endokarditis und Klappendysfunktion umfasst.
Les patients présentant une valvulopathie cardiaque ou une prothèse valvulaire sont vus de plus en plus fréquemment en pratique courante. Le traitement médical et l\'évaluation des patients avec valvulopathie avant l\'intervention pour remplacement valvulaire, mais aussi le traitement post-opératoire son complexes et pris en charge par les généralistes, les cardiologues et les chirurgiens cardiaques. Dans cette mini-revue nous allons discuter en premier lieu l\'évaluation pré-opératoire des deux valvulopathies les plus fréquentes, à savoir la sténose aortique et la régurgitation mitrale. Nous allons discuter ensuite la prise en charge post-opératoire, celle-ci incluant le traitement par anticoagulant, le suivi régulier et l\'approche diagnostique des complications telles que la thromboembolie, l\'hémolyse, l\'endocardite et la dysfonction valvulaire.