Transcatheter aortic valve implantation with a giant vegetation successfully treated with antibiotics: insights into a new group of patients with endocarditis

During recent years, transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option for patients with severe symptomatic aortic stenosis who are at high surgical risk. Although infective endocarditis (IE) is a potential and serious complication in this group of patients, the best therapeutic approach for IE in patients with TAVI has not been well established. Here, the case is reported of a patient with a giant vegetation after TAVI infection that was successfully treated without surgery. The hope is to provide some clinical insight into this new group of patients with IE.

Thromboembolic risk in atrial fibrillation: association between left atrium mechanics and risk scores. A study based on 3D wall-motion tracking technology

BACKGROUND/OBJECTIVES

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a significantly high risk of stroke and systemic embolism. The aim of our study was to assess the association between left atrium (LA) mechanics measured by 3D wall-motion tracking (3DWMT) technology and the most common thromboembolic risk scores (CHADS2, CHA2DS2-VASc).

METHODS

A total of 101 consecutive patients with permanent AF referred were included. Conventional bidimensional (2D) LA parameters, and LA mechanics by means of 3DWMT were studied. Association between LA 2D and 3DWMT parameters and both risk scores was evaluated as well as its correlation with every component of the score individually.

RESULTS

Mean age was 78 ± 10 years. Mean CHADS2 was 2.7 ± 1.3 and mean CHA2DS2-VASc was 4.4 ± 1.7. Values of 2D and 3DWTM LA parameters were: 2D area 26.4 ± 9.7 cm(2) , 2D volume index 49.4 ± 10.1 mL/m(2) , 3DWMT left atrial emptying fraction (LAEF) 15.9 ± 8.4%, longitudinal strain 9.1 ± 4.5% and area strain 14.9 ± 8.8%. Linear regression analysis showed statistically significant correlation between LA longitudinal strain and LAEF with CHADS2 and CHA2DS2-VASc scores. For each 10% variation in longitudinal strain, CHADS2 and CHA2DS2-VASc scores change in 0.7 and 0.8 points, respectively.

CONCLUSIONS

Left atrial longitudinal strain and emptying fraction assessed by 3D WMT technology have correlation with both CHADS2 and CHA2DS2-VASc scores. Each 10% of variation in longitudinal strain represents a 0.7 and 0.8 points change in those risk scores. LA mechanics evaluation might provide additional value to risk scores and could be considered to be a predictor of stroke in patients with AF.

Comparison of clinical features of left-sided infective endocarditis involving previously normal versus previously abnormal valves

Native valve infective endocarditis (IE) in patients with normal valves has increased in the last decades. Whether patients with normal valves present a similar prognosis to those with pathologic valves is unresolved. Our aim is to describe epidemiologic and clinical differences between patients with left-sided IE and normal valves and those with native pathologic valves. We analyzed 945 consecutive episodes of IE, 435 of which involved left-sided nonprosthetic IE. They were classified into 2 groups: episodes in normal valves (normal group, n=173) and episodes in pathologic valves (abnormal group, n=262). Patients in the normal group were younger, Staphylococcus aureus and Streptococcus bovis were more frequently isolated, and vegetations were more frequently found. Heart failure, septic shock, and the need for surgery or death were more common. Multivariate analysis identified the following as factors independently associated with normal valve IE: age<65 years, S bovis, S aureus, heart failure, and vegetation detection. Factors independently associated with in-hospital events included S aureus, periannular complications, heart failure, and septic shock development. In conclusion, compared with patients with abnormal valve IE, patients with IE on normal valves were younger, had a more virulent microbiological profile, developed heart failure and septic shock more frequently, needed more surgical procedures, and had worse prognosis.

Atopic dermatitis guideline. Position paper from the Latin American Society of Allergy, Asthma and Immunology

As in other regions, the incidence of atopic dermatitis in Latin America has been increasing in recent years. Although there are several clinical guidelines, many of their recommendations cannot be universal since they depend on the characteristics of each region. Thus, we decided to create a consensus guideline on atopic dermatitis applicable in Latin America and other tropical regions, taking into account socio-economic, geographical, cultural and health care system characteristics. The Latin American Society of Allergy Asthma and Immunology (SLAAI) conducted a systematic search for articles related to the pathophysiology, diagnosis and treatment of dermatitis using various electronic resources such as Google, Pubmed, EMBASE (Ovid) and Cochrane data base. We have also looked for all published articles in Latin America on the subject using LILACS (Latin American and Caribbean Literature on Health Sciences) database. Each section was reviewed by at least two members of the committee, and the final version was subsequently approved by all of them, using the Delphi methodology for consensus building. Afterward, the final document was shared for external evaluation with physicians, specialists (allergists, dermatologists and pediatricians), patients and academic institutions such as universities and scientific societies related to the topic. All recommendations made by these groups were taken into account for the final drafting of the document. There are few original studies conducted in Latin America about dermatitis; however, we were able to create a practical guideline for Latin America taking into account the particularities of the region. Moreover, the integral management was highlighted including many of the recommendations from different participants in the health care of this disease (patients, families, primary care physicians and specialists). This practical guide presents a concise approach to the diagnosis and management of atopic dermatitis that can be helpful for medical staff, patients and their families in Latin America.

Prognostic implications of diabetes in patients with left-sided endocarditis: findings from a large cohort study

Patients with diabetes mellitus (DM) have a higher incidence of infections, and those with bacteremia are more prone to develop sepsis and infective endocarditis (IE). Nevertheless, data concerning the impact of DM on the prognosis of patients with IE are limited and sometimes contradictory. We examined the impact of DM on the inhospital outcome of left-sided IE in a large cohort of patients. We studied 594 consecutive episodes of left-sided IE diagnosed at 3 tertiary care centers. They were divided into 2 groups: episodes in patients with DM (n = 114) and episodes in patients without DM (n = 480). We retrospectively analyzed the influence of DM therapy on patient outcome. Compared to patients without DM, patients with DM were older (67 ± 10 vs. 60 ± 15 yr; p < 0.001), less frequently male (53.5% vs. 67.9%; p = 0.004), and more commonly had chronic renal failure (23.9% vs. 6.9%; p < 0.001) and chronic obstructive pulmonary disease (14.6% vs. 7.8%; p = 0.019). Enterococcus (14.9% vs. 7.4%; p = 0.011) and Streptococcus bovis (8.8% vs. 3.8%; p = 0.024) were isolated more frequently. In the univariable analysis, septic shock (29.2% vs. 16.4%; p = 0.005) and mortality (43.5% vs. 30.0%; p = 0.008) were more common among patients with DM than in those without. Considering the different treatments for DM, septic shock (33.3%; p = 0.011) and death (50.8%; p = 0.012) were more frequent in patients receiving oral medication to treat diabetes than in patients with the other treatment modalities. However, multivariable analysis showed that DM had an independent association with development of septic shock (OR 2.282; 95% CI 1.186-4.393), but it was not a predictor of inhospital mortality.Staphylococci were the most frequently involved microorganisms in all patients; however, Enterococcus and Streptococcus bovis were more frequently isolated from individuals with DM and left-sided IE, whereas viridans group streptococci were more commonly isolated from those with left-sided IE who did not have DM. DM was independently associated with the development of septic shock, but it was not an independent predictor of inhospital mortality in patients with left-sided IE.

Symptomatic peripheral mycotic aneurysms due to infective endocarditis: a contemporary profile

Peripheral mycotic aneurysms (PMAs) are a relatively rare but serious complication of infective endocarditis (IE). We conducted the current study to describe and compare the current epidemiologic, microbiologic, clinical, diagnostic, therapeutic, and prognostic characteristics of patients with symptomatic PMAs (SPMAs). A descriptive, comparative, retrospective observational study was performed in 3 tertiary hospitals, which are reference centers for cardiac surgery. From 922 definite IE episodes collected from 1996 to 2011, 18 patients (1.9%) had SPMAs. Because all SPMAs developed in left-sided IE, we performed a comparative study between 719 episodes of left-sided IE without SPMAs and 18 episodes with SPMAs. We found a higher frequency of intravenous drug abuse, native valve IE, intracranial bleeding, septic emboli, multiple embolisms, and IE diagnostic delay >30 days in patients with SPMAs than in patients without SPMAs. The causal microorganisms were gram-positive cocci (n =10), gram-negative bacilli (n = 2), gram-positive bacilli (n = 3), Bartonella henselae (n = 1), Candida albicans (n = 1), and negative culture (n = 1). The median IE diagnosis delay was 15 days (interquartile range [IQR], 13-33 d) in the case of high-virulence microorganisms versus 45 days (IQR, 30-240 d) in the case of low- to medium-virulence microorganisms. Twelve SPMAs were intracranial and 6 were extracranial. In 10 cases (8 intracranial and 2 extracranial), SPMAs were the initial presentation of IE; the remaining cases developed symptoms during or after finishing parenteral antibiotic treatment. The initial diagnosis of intracranial SPMAs was made by computed tomography (CT) or magnetic resonance imaging in 6 unruptured aneurysms and by angiography in 6 ruptured aneurysms. The initial test in extracranial SPMAs was Doppler ultrasonography in limbs, CT in liver, and coronary angiography in heart. Four (3 intracranial, 1 extracranial) of 7 (6 intracranial, 1 extracranial) patients treated only with antibiotics died. Surgical resection was performed in 7 (3 intracranial, 4 extracranial) and endovascular repair in 4 (3 intracranial, 1 extracranial) patients; all of them survived. In conclusion, we found that SPMAs were a rare complication of IE that developed only in left-sided IE, and especially in native valves. Intracranial hemorrhage, embolism, multiple embolisms, and diagnostic delay of IE were more common in patients with SPMAs. The microbiologic profile was diverse, but microorganisms of low-medium virulence were predominant, and had a greater delayed diagnosis of IE than those caused by microorganisms of high virulence. SPMAs were often the initial presentation of IE. The most common location of SPMAs was intracranial. Noninvasive radiologic imaging techniques were the initial imaging test in intracranial unruptured SPMAs and in most extracranial SPMAs. Surgical and endovascular treatments were safe and effective. Endovascular treatment could be the first line of treatment in selected cases. Mortality was high in those cases treated only with antibiotics.

Prognostic role of persistent positive blood cultures after initiation of antibiotic therapy in left-sided infective endocarditis

AIM

Persistent infection is not a scientific evidence-based definition. The guidelines of infective endocarditis (IE) establish a cut-off point of 7-10 days, which is arbitrary and probably too long. Our hypothesis is that persistent positive blood cultures after 48-72 h from the initiation of antibiotic therapy are associated with a worse prognosis in patients with left-sided IE.

METHODS AND RESULTS

We repeated blood cultures after 48-72 h of the initiation of the antibiotic treatment in 407 patients with left-sided IE of a total of 692 episodes consecutively diagnosed from 1996 to 2011. We have compared the profile of patients whose blood cultures became negative and those with persistent positive blood cultures. We performed a multivariate logistic regression model to determine the prognostic implication of persistent positive blood cultures. Of 256 patients with positive blood cultures at admission, 89 (35%) had persistent positive cultures after 48-72 h from the initiation of the antibiotic treatment. Persistent positive blood cultures (OR: 2.1; 95% CI: 1.2-3.6), age (OR: 1.026; 95% CI: 1.007-1.046), Staphylococcus aureus infection (OR: 3.3; 95% CI: 1.6-6.6), heart failure (OR: 2.8; 95% CI: 1.6-4.7), and renal failure (OR: 2.9; 95% CI: 1.8-4.9) were found to be independently associated with higher in-hospital mortality.

CONCLUSIONS

The presence of persistent positive blood cultures is an independent risk factor for in-hospital mortality which doubles the risk of death of patients with left-sided IE. It should be taken into account in the risk stratification of these patients.

Contemporary epidemiology and prognosis of septic shock in infective endocarditis

AIMS

The prognosis of patients with infective endocarditis (IE) remains poor despite the great advances in the last decades. One of the factors closely related to mortality is the development of septic shock (SS). The aim of our study was to describe the profile of patients with IE complicated with SS, and to identify prognostic factors of new-onset SS during hospitalization.

METHODS AND RESULTS

We conducted a prospective study including 894 episodes of IE diagnosed at three tertiary centres. A backward logistic regression analysis was undertaken to determine prognostic factors associated with SS development. Multivariable analysis identified the following as predictive of SS development: diabetes mellitus [odds ratio (OR) 2.06; confidence interval (CI) 1.16-3.68], Staphylococcus aureus infection (OR: 2.97; CI: 1.72-5.15), acute renal insufficiency (OR: 3.22; CI: 1.28-8.07), supraventricular tachycardia (OR: 3.29; CI: 1.14-9.44), vegetation size ≥15 mm (OR: 1.21; CI: 0.65-2.25), and signs of persistent infection (OR: 9.8; CI: 5.48-17.52). Risk of SS development could be stratified when combining the first five variables: one variable present: 3.8% (CI: 2-7%); two variables present: 6.3% (CI: 3.2-12.1%); three variables present: 14.6% (CI: 6.8-27.6%); four variables present: 29.1% (CI: 11.7-56.1%); and five variables present: 45.4% (95% CI: 17.5-76.6%). When adding signs of persistent infection, the risk dramatically increased, reaching 85.7% (95% CI: 61.2-95.9%) of risk.

CONCLUSIONS

In patients with IE, the presence of diabetes, acute renal insufficiency, Staphylococcus aureus infection, supraventricular tachycardia, vegetation size ≥15 mm, and signs of persistent infection are associated with the development of SS.

Reassessment of blood culture-negative endocarditis: its profile is similar to that of blood culture-positive endocarditis

INTRODUCTION AND OBJECTIVES

Left-sided infective endocarditis with blood culture-negative has been associated with delayed diagnosis, a greater number of in-hospital complications and need for surgery, and consequently worse prognosis. The aim of our study was to review the current situation of culture-negative infective endocarditis.

METHODS

We analyzed 749 consecutive cases of left-sided infective endocarditis, in 3 tertiary hospitals from June 1996 to 2011 and divided them into 2 groups: group I (n=106), blood culture-negative episodes, and group II (n=643) blood culture-positive episodes. We used Duke criteria for diagnosis until 2002, and its modified version by Li et al. thereafter.

RESULTS

Age, sex, and comorbidity were similar in both groups. No differences were found in the proportion of patients who received antibiotic treatment before blood culture extraction between the 2 groups. The interval from symptom onset to diagnosis was similar in the 2 groups. The clinical course of both groups during hospitalization was similar. There were no differences in the development of heart failure, renal failure, or septic shock. The need for surgery (57.5% vs 55.5%; P=.697) and mortality (25.5% vs 30.6%; P=.282) were similar in the 2 groups.

CONCLUSIONS

Currently, previous antibiotic therapy is no longer more prevalent in patients with blood culture-negative endocarditis. This entity does not imply a delayed diagnosis and worse prognosis compared with blood culture-positive endocarditis. In-hospital clinical course, the need for surgery and mortality are similar to those in patients with blood culture-positive endocarditis. Full English text available from:www.revespcardiol.org.

Evaluation of calcaneal quantitative ultrasound in a primary care setting as a screening tool for osteoporosis in postmenopausal women

Screening of osteoporosis by quantitative ultrasound (QUS) has become widely available in Europe, but no clear strategies for its clinical use have been established. The aim of this study was to validate the use of QUS in a cross-sectional study carried out in three primary care centers. Measurements of calcaneal QUS and bone mineral density (BMD) at proximal femur were obtained by dual-energy X-ray absorptiometry (DXA). Osteoporosis was diagnosed by DXA T-score <or= -2.5 at the femoral neck. Sensitivity, specificity, kappa index, and receives operator characteristics (ROC) curve QUS values were calculated with respect to the standard reference. Both positive and negative likelihood ratios (LR) were used to calculate the optimum cut-off levels. Two hundred and sixty-seven women aged 65 or older were included. Fifty-five percent had osteoporotic femoral neck BMD values (T-score <or= -2.5). The same threshold for QUS yielded a lower prevalence of osteoporosis (10%). Women with BMD diagnosis of osteoporosis were older and showed lower age-adjusted values for all QUS parameters (p < 0.001). Area under the curve (AUC) ranged from 0.662-0.678 for the different QUS parameters; correlation and concordance of all parameters with femoral neck BMD were statistically significant (p < 0.001). Cut-off values calculated from the AUC yielded 61.1% sensitivity and 65.3% specificity for the best QUS parameter (i.e., Estimated Heel T-score <or= -1.55). Estimated Heel T-score values of +0.05 or above ruled out osteoporosis (LR 0.18), whereas those -2.50 or below supported the diagnosis (LR 5.98). The application of these cutoff points allowed classification of 22.1% of cases. In conclusion, in postmenopausal women, QUS screening conclusively confirms or rules out osteoporosis in approximately one-fifth of cases, thereby avoiding the need for a DXA measurement.