Epidemiology, microbiology, and outcomes of infective endocarditis in a tertiary center in Jordan

BACKGROUND

Infective endocarditis (IE) is a relatively rare but serious and life-threatening disease with substantial mortality and morbidity despite progress in diagnostic and treatment techniques. The aim of this study is to investigate the epidemiology, clinical characteristics, microbiological profile, and outcomes of IE patients in a tertiary care facility in Jordan, the Jordan University Hospital (JUH).

METHODS

This is a retrospective case series study which was conducted at JUH. A total of 23 patients with either definite or possible IE according to the Modified Duke Criteria were included in the study. Medical records were reviewed, and relevant information was collected. Descriptive data analysis was performed.

RESULTS

Our study identified a total of 23 patients with infective endocarditis; 65.2% were males, with a mean age of 40.4 years. The majority of patients had an underlying cardiac disease (60.9%), with the most common being congenital heart diseases (17.4%). The most commonly affected valves were the left-side heart valves, with the mitral valve (52.2%) being the most common followed by the aortic valve (34.8%). The most common organism detected in blood culture was Streptococcus viridans (21.7%) followed by methicillin-resistant Staphylococcus aureus. The most common complications among the patients were heart failure and septic shock, and the mortality rate among the patients was 13%.

CONCLUSION

In patients with endocarditis, Streptococcus viridans is the most common culture-positive bacteria at JUH. One third of our patients needed surgical intervention and the mortality rate was 13%.

Prevalence of valvular heart disease in cardiac amyloidosis and impact on survival

BACKGROUND

Limited data exists on the prognostic impact of valvular heart disease in cardiac amyloidosis (CA). We therefore sought to define the prevalence of valvular disease in patients with CA and assess the effects of significant valve disease on survival.

METHODS

This multi-center retrospective cohort study included consecutive patients with confirmed transthyretin (TTR) or light chain (AL) amyloidosis. Echocardiographic data closest to the date of amyloid diagnosis was reviewed, and severity was graded according to ASE guidelines. Kaplan-Meier survival analysis was performed to compare survival between patients with moderate or greater valve disease against those with mild or less disease.

RESULTS

We included 345 patients (median age 76 years; 73 % men; 110 AL, 235TTR). The median survival for the total patient cohort with cardiac amyloidosis was 2.92 years, with 30 % of patients surviving at five years after their diagnosis. Median survival comparing AL vs ATTR was 2.58 years vs 2.82 years (p = 0.67) The most common valvular abnormalities in the total cohort were mitral (62 %) and tricuspid (66 %).regurgitation There was a statistically significant difference in median survival between patients with no or mild MR compared to those with moderate or severe MR (2.92 years vs 3.35 years, p = 0.0047) (Fig. 5). There was a statistically significant difference in median survival in patients with no or mild TR compared to those with moderate or severe TR (3.35 years vs 2.3 years, p = 0.015).

CONCLUSION

Our study demonstrates a significant prevalence of mitral and tricuspid regurgitation in CA, with patients with moderate to severe MR and TR having a poorer prognosis.

Pulmonary artery sarcoma and severe valvular diseases in late-septuagenarian women: was 2-stage surgery an appropriate strategy? A case report

BACKGROUND

Pulmonary artery sarcomas (PASs) are rare, and complete tumor resection is often difficult at the time of detection. We encountered a case of PAS that was thought to be resectable; however, the patient had severe symptomatic valvular disease. We faced a difficult decision regarding the surgical strategy.

CASE PRESENTATION

A 76-year-old female presented with a history of polysurgery for multiple primary cancers. She was referred to our department with a calcified mass in the right pulmonary artery (PA) and severe symptomatic valvular disease. After a discussion with the cardiovascular surgeon, we decided to perform a two-stage surgery. She underwent valvuloplasty through a median sternotomy, resulting in an improvement in her exertional dyspnea. The tumor was removed three months later with a right upper lobectomy and PA patch reconstruction through a posterolateral thoracotomy. When the PA was opened, the edge of the tumor was entrapped by vascular clamp forceps because of insufficient dissection of the adhesions between the superior vena cava and the right main PA resulting from the first operation. The patient underwent proton therapy twice for chest wall metastases which recurred three months after surgery, and local recurrence in the PA was diagnosed five months after surgery. The patient was alive with stable disease 25 months after surgery.

CONCLUSION

Two-stage surgery for PAS and valvular disease resulted in incomplete resection of the PAS in the right PA. It is important not to underestimate surgical adhesions due to the initial surgery and to consider and implement measures to prevent adhesions of critical vessels during the second operation.

Veno-arterial extracorporeal membrane oxygenation as a perioperative support to redo cardiac surgery for inoperable adult patients: a case series

Background

The present article describes three cases of patients in cardiogenic shock (CS) with previous cardiac surgery that made them initially inoperable. Perioperative support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) improved haemodynamic status and results in these high-risk patients.

Case summary

Case 1 is a 57-year-old male morbidly obese with previous aortic valve replacement (AVR) who presented with chest pain and developed cardiac arrest. Cardiopulmonary resuscitation and femoral VA-ECMO were initiated. Three days later, a redo AVR was performed. Veno-arterial extracorporeal membrane oxygenation was maintained for 12 days, followed by 7 days of veno-venous ECMO for complete recovery. Case 2 features a 39-year-old male with two previous mitral valve replacements (MVRs). The first is due to papillary muscle rupture, and the second is due to endocarditis of the mitral prosthesis. He presented with CS and pulmonary oedema. Emergency surgery was performed and the patient was then placed in VA-ECMO. Weaning off was achieved 3 days after surgery. Case 3 is a 21-year-old female with a previous MVR due to rheumatic disease. She presented with CS, severe mitral prosthesis stenosis, and a pulmonary embolism. Femoral VA-ECMO was initiated, and one day later, she underwent a redo MVR operation. Extracorporeal membrane oxygenation was discontinued 4 days later.

Discussion

Dysfunctional prosthetic valves leading to CS may benefit from a redo cardiac operation supported by a perioperative VA-ECMO to optimize haemodynamic status. Despite the results from risk prediction scores, this approach has the potential to reduce operative mortality in initial inoperable patients and allow a definitive redo cardiac surgery.

Veterinary echocardiographers' preferences for left atrial size assessment in dogs: the BENEFIT project

INTRODUCTION/OBJECTIVES

Veterinary echocardiographers' preferences for left atrial (LA) size assessment in dogs have never been systematically investigated. The primary aim of this international survey study was to investigate echocardiographers' preferences for LA size assessment in dogs. The secondary aim was to investigate echocardiographers' preferences for assessing LA size in subgroups based on geographic, demographic, and professional profiles.

ANIMALS, MATERIALS, AND METHODS

An online survey instrument was designed, verified, and distributed globally to the veterinary echocardiographers.

RESULTS

A total of 670 echocardiographers from 54 countries on six continents completed the survey. Most echocardiographers (n = 621) used linear two-dimensional (2D)-based methods to assess LA size, 379 used subjective assessment, and 151 used M-mode-based methods. Most commonly, echocardiographers combined linear 2D-based methods with subjective assessment (n = 222), whereas 191 used linear 2D-based methods alone. Most echocardiographers (n = 436) using linear 2D-based methods preferred the right parasternal short-axis view and indexed the LA to the aorta. Approximately 30% (n = 191) of the echocardiographers who performed linear measurements from 2D echocardiograms shared the same preferences regarding dog position, acquisition view, indexing method, and identification of the time-point used for the measurement. The responses were comparably homogeneous across geographic location, training level, years of performing echocardiography, and type of practice.

DISCUSSION/CONCLUSION

Most veterinary echocardiographers assessed LA size in dogs using linear 2D echocardiography from a right parasternal short-axis view, and by indexing the LA to the aorta. The respondents' preferences were similar across geographic, demographic, and professional backgrounds.

Increasing baseline aortic valve peak flow velocity is associated with progression of aortic valve stenosis in osteoporosis patients-a possible link to low vitamin D status

PURPOSE

The purpose of this study was to investigate the morphological characteristics of the aortic valve and identify factors associated with the progression of aortic valve stenosis (AS) in osteoporosis patients.

METHODS

In this single-center prospective cohort study, we recruited 10 patients (mean age: 75 ± 7 years, 90% female) who were taking anti-resorptive medicines at the outpatient clinic of University of Miyazaki Hospital, Japan. Baseline assessments, including transthoracic echocardiogram, blood sampling, and dual energy X-ray absorptiometry, were performed. Follow-up assessments were conducted at 6, 12, 18, and 24 months.

RESULTS

During the 2-year follow-up, three patients with aortic valve peak flow velocity (AV PFV) ≥2 m/s at baseline developed moderate AS, which is defined as AV PFV ≥3 m/s. However, seven patients with AV PFV <2 m/s did not exhibit any progression of AS. There were significant variations in terms of bone mineral density, T-score values, and biomarkers associated with bone turnover (i.e., bone alkaline phosphatase, tartrate-resistance acid phosphatase-5b) among the enrolled patients, but none of these factors were found to be associated with the progression of AS. All patients exhibited low vitamin D status, with a median level of 16.1 ng/mL (25th percentile, 9.7 ng/mL; 75th percentile, 23 ng/mL). The baseline levels of AV PFV values were negatively correlated with 25-hydroxyvitamin D levels, determined by univariate linear regression analysis (beta coefficient = -0.756, 95% confidence interval, -0.136 ̶ -0.023, p = 0.011).

CONCLUSION

Our data suggest that low vitamin D status might be a potential risk factor for the progression of AS in osteoporosis patients undergoing treatment with anti-resorptive medicines. Elderly patients with osteoporosis patients exhibited a subset of aortic valve stenosis. Our data suggest that the baseline aortic valve peak flow velocity predicts the progression of aortic valve stenosis, and there might be an association between the progression and the co-existing low vitamin D status in these patients.

A Readmission Risk Score for Transcatheter Aortic Valve Replacement: An Analysis of 200,000 Patients

OBJECTIVE

The objective of this study was to leverage a national database of TAVR procedures to create a risk model for 30-day readmissions.

METHODS

The National Readmissions Database was reviewed for all TAVR procedures from 2011 to 2018. Previous ICD coding paradigms created comorbidity and complication variables from the index admission. Univariate analysis included any variables with a P-value of ≤0.2. A bootstrapped mixed-effects logistic regression was run using the hospital ID as a random effect variable. By bootstrapping, a more robust estimate of the variables' effect can be generated, reducing the risk of model overfitting. The odds ratio of variables with a P-value <0.1 was turned into a risk score following the Johnson scoring method. A mixed-effect logistic regression was run using the total risk score, and a calibration plot of the observed to expected readmission was generated.

RESULTS

A total of 237,507 TAVRs were identified, with an in-hospital mortality of 2.2 %. A total of 17.4 % % of TAVR patients were readmitted within 30 days. The median age was 82 with 46 % of the population being women. The risk score values ranged from -3 to 37 corresponding to a predicted readmission risk between 4.6 % and 80.4 %, respectively. Discharge to a short-term facility and being a resident of the hospital state were the most significant predictors of readmission. The calibration plot shows good agreement between the observed and expected readmission rates with an underestimation at higher probabilities.

CONCLUSION

The readmission risk model agrees with the observed readmissions throughout the study period. The most significant risk factors were being a resident of the hospital state and discharge to a short-term facility. This suggests that using this risk score in conjunction with enhanced post-operative care in these patients could reduce readmissions and associated hospital costs, improving outcomes.

One-Year Healthcare Utilization and Expenditures Among Patients with Clinically Significant Mitral Regurgitation in Taiwan

INTRODUCTION

Mitral regurgitation (MR) is characterized by systolic blood flow reversal from the left ventricle to the left atrium. A 2019 study indicated that in the USA, clinically significant MR (sMR) is associated with a substantial healthcare cost burden. In Taiwan, few data are available to describe the clinical characteristics, treatment patterns, and economic burden of patients with sMR.

METHODS

Using the National Health Insurance Research Database (NHIRD), a national, detailed claims database of all 23 million residents of Taiwan, we conducted a retrospective cohort study to identify patients with sMR and quantify the impact of the disease on Taiwan's healthcare system. We classified patients with sMR into three cohorts based on disease etiology: functional MR (sFMR), degenerative MR (sDMR), and uncharacterized MR (sUMR).

RESULTS

We compared patient characteristics across cohorts and estimated attributable healthcare utilization and costs during the 12-month follow-up period. Our research shows that in Taiwan, patients with sFMR were older, sicker, and presented at casualty (emergency department) more frequently than those with sDMR and sUMR. Meanwhile, patients with sDMR had the highest 12-month healthcare expenditures across the cohorts.

CONCLUSION

These findings are inconsistent with what has been shown in the USA, which warrants further investigation.

Blood pressure changes during routine transthoracic echocardiography

Background

Increased afterload affects many of the flow dependent metrics assessed during transthoracic echocardiography (TTE) especially in the evaluation valvular disease. A single timepoint blood pressure (BP) may not accurately reflect the afterload present at the time of flow-dependent imaging and quantification. We assessed the magnitude of change in BP at discrete timepoints during routine TTE.

Method

We conducted a prospective study where participants underwent automated BP measurement while undergoing a clinically indicated TTE. The first reading was obtained right after the patient lay supine and subsequent readings were taken at 10-min intervals during image acquisition.

Result

We included 50 participants (66% were male, with a mean age of 64 years). After 10 min, 40 (80%) participants had a drop in systolic BP of >10 mmHg. Compared to the baseline, there was a significant drop in systolic BP (mean decrease 20.0 ± 12.8 mmHg; P < 0.05), and diastolic BP (mean decrease 15.7 ± 13.2 mmHg; P < 0.05) at 10 min. The systolic BP remained different from the baseline value throughout the duration of the study (average decrease from baseline to study end was 12.4 ± 16.0 mmHg, p < 0.05).

Conclusion

BP recorded just prior to TTE does not accurately reflect the afterload present during most of the study. This finding has important implications for valvular heart disease imaging protocols that incorporate flow dependent metrics, where the presence or absence of hypertension may lead to under- or over-estimation of disease severity.

Ferret Cardiology

Cardiac disease is relatively common in middle-aged to older ferrets and may comprise acquired or congenital disorders leading to problems with conduction, contractility, or outflow. Clinical signs are often seen in advanced stages of the disease, with lethargy, hind limb weakness, ascites, hepatosplenomegaly, and respiratory distress owing to pleural effusion or lung edema being prominent features. Diagnostic workup and therapeutic intervention largely follow guidelines such as those established for dogs and cats, with feline doses often serving as a starting point for therapy.

An intelligent probe with dual-emission in water and oil for lipid droplet specific imaging in human fibrocalcific aortic valvular leaflet

Lipid droplets (LDs) have been regarded as potential marker for study the pathologic processes and diagnosis of valvular heart disease. While conventional imaging strategy fail to precisely locate LDs in pathological tissues. Herein, a LDs specific probe ECPID with special feature of single-excitation but dual-emission in oil (520 nm) and water (628 nm) was prepared for LDs imaging. ECPID exhibited good biocompatibility, great performance in intracellular and tissular LDs imaging, which would help to reveal the pathologic process of human fibrocalcific aortic valvular leaflet. Our work offers a novel approach for accurate imaging LDs in situ and paves a way to study the pathologic processes of valvular disease.

Echocardiographic findings in acromegaly: prevalence of concentric left ventricular remodeling in a large single-center cohort

PURPOSE

Acromegaly is a rare disease and is associated with increased cardiovascular (CV) morbidity and mortality, especially in patients with uncontrolled disease. We aimed to analyze the prevalence and severity of cardiomyopathy and valvular heart disease in a large cohort of patients with a confirmed acromegaly diagnosis, at baseline and after treatment.

METHODS

We retrospectively reviewed an institutional approved database; 190 patients with confirmed acromegaly and follow-up data available (years 2006-2018). Patients with at least one baseline echocardiogram, were included. Demographic, disease control and echocardiogram variables were collected for analysis.

RESULTS

Of the 190 patients 110 (58%) had a baseline echocardiogram and 43 (39.1%) had at least one follow-up echocardiogram after surgical, medical or multimodal treatment. Baseline left ventricular hypertrophy (LVH) prevalence was 17.8% (64.7% concentric; 35.3% eccentric), diastolic and systolic dysfunction, and overt cardiomyopathy with heart failure were 15.8, 7.9, and 3.0%, respectively. Concentric remodeling of the left ventricle (LV) was noted in 31.4% of patients without LVH. Valve defects were found in 87.3% of patients (14.6% with significant valvular heart disease).

CONCLUSION

Early diagnosis of acromegaly and disease control should be attempted to prevent LVH/LV dysfunction and development of valvular heart disease. Concentric LV remodeling develops prior to obvious LV hypertrophy in almost a third of patients with acromegaly, which is a novel finding. Similar to other epidemiological studies, we found a high prevalence of LVH/LV dysfunction. Although possible, reversal of systolic and diastolic dysfunction is sporadic after treatment of acromegaly.

The characteristics of mitral regurgitation: Data from patients admitted following acute myocardial infarction

Data were collected on patients admitted to the Queen Elizabeth Hospital Birmingham with type-1 myocardial infarction during 2016 and 2017 inclusively, who were treated by percutaneous intervention and had pre-discharge transthoracic echocardiography. The data were obtained from prospectively maintained hospital databases and records. Echocardiography was performed and reported contemporaneously by accredited echocardiographers. The purpose was to understand the prevalence and characteristics of mitral regurgitation (MR) after acute MI, including patients with ST-elevation (STEMI) and non-ST elevation MI (NSTEMI). MR was observed in 294/1000 patients with the following relative severities: mild = 76%, moderate = 21%, severe = 3% [1]. MR was graded by multiparametric quantification including proximal isolvelocity surface area (PISA), vena contracta (VC), effective regurgitant orifice area (EROA) and regurgitant volume (RVol). Amongst all patients with MR (n=294), PISA was performed in 89/294 (30%), VC 75/294 (26%), EROA in 53/294 (18%) and RVol in 26/294 (9%). Amongst patients with moderate or severe MR (n=70), PISA was performed in 57/70 (81%), VC in 55/70 (79%), EROA in 46/70 (66%) and RVol in 25/70 (36%). Characteristics of MR following acute MI were also assessed including frequency of reported leaflet thickness (259/294 = 88%) and mitral annular calcification (102/294 = 35%). Furthermore, the effect of MI on pre-existing MR was investigated and patients with pre-existing MR who continue to have MR after acute MI were found to have progression of MR by one grade in approximately 25% of cases. Finally, using Cox proportional hazards univariate analysis, significant factors associated with mortality in patients with MR post-MI include age (HR 1.065; 95% CI 1.035-1.096; p<0.001), creatinine clearance, (HR 0.981; 95% CI 0.971-0.991; p<0.001), left ventricular ejection fraction (LVEF) (HR 0.966; 95% CI 0.948-0.984; p<0.001), indexed left ventricular end-diastolic volume (LVEDVi) (HR 1.016; 95% CI 1.003-1.029; p=0.018), indexed left ventricular end-systolic volume (LVESVi) (HR 1.021; 95% CI 1.008-1.034; p=0.001), indexed left atrial volume (HR 1.026; 95% CI 1.012-1.039; p<0.001), and those with intermediate likelihood of pulmonary hypertension (pHTN) (HR 2.223; 95% CI 1.126-4.390; p=0.021); or high likelihood of pHTN (HR 5.626; 95% CI 2.189-14.461; p<0.001). Age and LVEF were found to be independent predictors of mortality on multivariate analysis [1].

Heart valve disease in hypocomplementemic urticarial vasculitis syndrome: from immune-mediated degeneration to embolic complications of infective endocarditis-a case report

Background

Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare disease due to small vessel inflammation and characterized by chronic urticarial vasculitis and arthritis. Multi-organ manifestations may include glomerulonephritis, ocular inflammation (uveitis, episcleritis), and recurrent abdominal pain. To the best of our knowledge, just other nine cases of HUVS with cardiac valvular involvement have been reported in the literature.

Case summary

A 32-year-old woman presented to the emergency department because of a cerebral haemorrhage. She suffered from a severe HUVS form with cardiac valvular involvement. In the previous years, she underwent cardiac surgery twice for aortic and mitral valves immune-mediated degeneration. The neurologic event was secondary to Listeria monocytogenes aortic endocarditis, complicated by a cerebral embolism and periaortic abscess.

Discussion

Patients with HUVS rarely present valvular heart disease. The latter is mostly secondary to an inflammatory process. Valve degeneration and immunosuppressive therapy increase the risk of infective endocarditis, with dramatic consequences for the prognosis of these patients. Valvular involvement is a sporadic but potentially fatal complication of HUVS, which should be taken in mind in the multidisciplinary evaluation of these patients.

Alterations in Intracardiac Flow Patterns Affect Mitral Leaflets Dynamics in a Model of Ischemic Mitral Regurgitation

PURPOSE

This study was to evaluate the effects of ischemic mitral regurgitation (IMR) on vortex formation and leaflet dynamics using an established porcine infarct model of IMR.

METHODS

Using direct coronary ligation, five animals were subjected to a posterolateral myocardial infarction (MI) followed by an MRI at 12-weeks post MI. MR imaging consisted of 4D time-resolved left ventricular (LV) flow, full coverage 2D LV cine, and high resolution 2D cine of mitral valve dynamics. Five additional naïve animals underwent identical imaging protocols to serve as controls. Image analysis was performed to obtain mitral transvalvular flows as well as LV volumes throughout the cardiac cycle. In addition, anterior to posterior mid-leaflet tip distances were measured throughout the cardiac cycle for determination of temporal leaflet dynamics.

RESULTS

It was found IMR caused asymmetric vortex ring formation with the anterior vortex having a lower vorticity relative to its posterior counterpart. In contrast, normal ventricles create symmetric and tightly curled vortices in the basal chamber just underneath the mitral leaflets which conserve kinetic energy and aid in effective ejection. IMR animals were also evaluated for leaflet separation and were found to have a greater leaflet opening and achieved peak vorticity and peak leaflet opening later than control animals.

CONCLUSION

In conclusion, this study shows the effects that altered vortex formation, due to IMR, can have on ventricular filling and leaflet dynamics. These findings have important implications for understanding blood flow through the dilated heart and how ring annuloplasty and volume reduction interventions may influence mitral valve dynamics.

Relapsing polychondritis, a rare cause of valvulopathy: A review of the medical literature

Relapsing polychondritis (RP) is an inflammatory disease that involves cartilaginous structures predominantly in the nose, ears, and respiratory tract. Cardiovascular involvement is not common. Despite this, they are the second cause of death in patients with RP. The structures usually affected by this disease are the heart valves, with regurgitation being the most common valvulopathy. We present the case of a patient without the previous diagnosis of RP who was referred to our institute with heart failure secondary to aortic regurgitation, initially attributed to endocarditis.

Relapsing polychondritis, a rare cause of valvulopathy: a review of the medical literature

Relapsing polychondritis is an inflammatory disease that involves cartilaginous structures predominantly in the nose, ears and respiratory tract. Cardiovascular involvement is not common. Despite this, they are the second cause of death in patients with relapsing polychondritis. The structures usually affected by this disease are the heart valves, with regurgitation being the most common valvulopathy. We present the case of a patient without previous diagnosis of relapsing polychondritis who was referred to our Institute with heart failure secondary to aortic regurgitation, initially attributed to endocarditis.

Haemoptysis: just another case of endocarditis? A case report

Background 

Pulmonary arteriovenous malformations (PAVM) are rare, and most cases are congenital. They require prompt recognition and management particularly in patients presenting with hypoxia and haemoptysis. We describe a unique case of recurrent endocarditis causing pulmonary artery aneurysms (PAAs) and formation of PAVM.

Case summary 

A 60-year-old woman presented with dyspnoea, haemoptysis, and severe hypoxia. Her background was significant for previous pacemaker lead infection, refractory heart failure secondary to severe tricuspid valve distortion by her pacemaker lead, tricuspid and mitral valve replacements complicated by recurrent endocarditis over several years. Two years prior to her current presentation computed tomography (CT) scanning revealed new small PAAs thought possibly to be mycotic in origin. After her current presentation, prompt high-resolution CT scanning of her chest with contrast revealed significant pulmonary haemorrhage and new clusters of PAVM. Urgent pulmonary angiography confirmed PAVM and was successfully treated with coil embolization. Her dyspnoea, pulmonary haemorrhage, and hypoxia resolved.

Discussion 

Acquired causes account for a very small percentage of PAVM and the mechanism of their development is unknown. As she had recurrent right-sided endocarditis and her PAAs developed following this, with new PAVM developing 2 years later; we hypothesize that they were causally related. We believe this is the first case of recurrent left- and right-sided endocarditis leading to formation of PAAs and development of PAVM presenting with significant hypoxia and haemoptysis requiring prompt intervention.

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

Background

Early treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve.

Methods

SURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected.

Results

The study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study.

Conclusions

These results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.

Risk factors for second hip fracture in elderly patients: an age, sex, and fracture type matched case-control study

PURPOSE

Prevention of second hip fracture is mandatory for orthopedic surgeons. We aimed to clarify the incidence and duration of second hip fracture, to compare survival rate and walking ability of patients with a second hip fracture to that of patients with a unilateral fracture, and to identify risk factors for second hip fracture using matched case-control methods.

METHODS

This retrospective study conducted in a single tertiary emergency center comprised 119 patients with second hip fractures who underwent bilateral operations at our institution from 2007 to 2017 (second hip fracture group [Group A]). The control group (Group B) comprised 357 patients matched to Group A for age, sex, and fracture type.

RESULTS

The incidence of second hip fracture was 7.6%, and the average interval from initial fracture to second hip fracture was 22.8 months. Significantly more patients in Group A had decreased postoperative walking ability. Five-year survival rates from initial fracture were 65.0% in Group A and 50.6% in Group B (P = 0.346). Dementia and heart disease were identified as independent risk factors (dementia: HR 2.08, 95% CI 1.27-3.41, P = 0.004; heart disease: HR 1.27, 95% CI1.11-3.22, P = 0.019). Valvular disease was also revealed to be a risk factor for heart disease (P = 0.0272).

CONCLUSIONS

The incidence of second hip fracture was not low. Although survival rates did not differ between the patients with or without second hip fracture, walking ability of patients with second hip fracture worsened. Dementia and cardiac disease could be risk factors for second hip fracture in elderly patients, and valvular disease might be associated with second hip fracture in patients with heart disease.

Carcinoid heart disease of gonadal primary presenting with hypoxia: a case report

Background

Carcinoid heart disease is a potential sequela of metastatic neuroendocrine tumour that has characteristic valve appearances. Patients can present with symptoms of carcinoid syndrome or be relatively asymptomatic until symptoms of progressive heart failure manifest.

Case summary

We present a case of a 54-year-old male who was admitted to the hospital for investigation of hypoxia. Transthoracic echocardiogram was suggestive of carcinoid heart disease which subsequently led to a diagnosis of metastatic neuroendocrine (carcinoid) tumour of the testicular primary. Work-up revealed a patent foramen ovale with evidence of the right to left interatrial shunt from severe tricuspid regurgitation as the cause of his hypoxia. Prior to surgical excision of the primary tumour, percutaneous patent foramen ovale closure was performed resulting in improved arterial oxygen saturation and symptomatic improvement.

Discussion

Carcinoid heart disease typically affects the right-sided cardiac valves and the tricuspid valve appearances were critical in leading to a diagnosis of a metastatic neuroendocrine tumour in our patient. This case demonstrates that percutaneous patent foramen ovale closure can be an effective intervention for hypoxia in those not managed surgically. A high index of suspicion should be maintained for gonadal primary carcinoid tumour when there is carcinoid heart disease in the absence of liver metastases.

The effects of interventional mitral valve repair using the MitraClip System on the results of pulmonary function testing, pulmonary pressure and diffusing capacity of the lung

BACKGROUND

The study analyzes changes in lung function, pulmonary pressure and diffusing capacity of the lung in patients with mitral valve regurgitation (MR) treated by MitraClip implantation.

METHODS

A total of 43 patients (19 women and 24 men with an average age of 78.0 ± 6.6 years) who were able to perform pulmonary function testing including diffusing capacity of the lung for carbon monoxide (DLCO), vital capacity (VC), total lung capacity (TLC), residual volume (RV) and forced expiratory volume in 1 s (FEV1) before and 6 weeks after MitraClip implantation participated in this study. Furthermore, clinical and echocardiographic parameters including systolic pulmonary artery pressure (sPAP), left ventricular ejection fraction (LVEF) and left atrial diameter (LAD) measurements were recorded in all patients.

RESULTS

The procedure was performed successfully in all 43 patients leading to a reduction of MR in 97.7% of cases. One patient died on day 4 after the intervention most likely due to pulmonary artery embolism. Six weeks after the implantation 79.1% of patients showed a MR of at most mild to moderate. Furthermore, we could demonstrate a significant reduction of systolic pulmonary artery pressure during follow-up (from 48.8 ± 11.4 mmHg to 42.9 ± 9.0 mmHg (t(41) = - 2.6, p = 0.01). However, no changes in LVEF were detected. Comparing pre and post implant lung function tests, no significant alterations were seen for VC, TLC, DLCO and FEV1. Though, in a subgroup of patients with moderate to severe preexisting deterioration of DLCO at the baseline (max. 50%) the MitraClip procedure resulted in a significant improvement in DLCO (37.8% ± 9.0 to 41.6% ± 10.0, p < 0.001).

CONCLUSIONS

Treatment of MR with the MitraClip system successfully reduces MR severity in the vast majority of patients. Consecutively, a reduction in pulmonary pressure could be observed, however no changes in LVEF were obvious. Lung function tests remained unaltered during follow-up. However, in a subgroup of patients with severe preexisting deterioration of DLCO the MitraClip procedure resulted in a significant improvement in DLCO.

TRIAL REGISTRATION

Name of the registry: Die Auswirkung der interventionellen Mitralklappenreparatur mit MitraClip-System auf die Ergebnisse der Lungenfunktionsmessung.

TRIAL REGISTRATION NUMBER

DRKS00022435; Date of registration: 09/07/2020 'Retrospectively registered'; URL of trial registry record: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022435 .

Continuous positive airway pressure improves work of breathing in pediatric chronic heart failure

BACKGROUND

Sleep disordered breathing (SDB) is common in adults with chronic heart failure (CHF), but its prevalence in children remains unclear. Continuous positive airway pressure (CPAP) is the treatment of SDB but deleterious hemodynamic effects have been reported.

METHODS

We prospectively analyzed SDB in children with CHF and the effect of CPAP on work of breathing (WOB) and cardiac index (CI). Children aged 6 months to 18 years old with CHF due to: 1) dilated cardiomyopathy (DM) with an ejection fraction < 45%, 2) functional single ventricle (SV) or 3) aortic or mitral valve disease awaiting surgery (VD) were eligible for the study. A polysomnography (PSG), measurement of WOB and CI during spontaneous breathing (SB) and CPAP (6, 8 and 10 cmH₂O) were performed.

RESULTS

Thirty patients with mean age of 6.4 ± 5 years were included (16 DM 16, 10 SV, 4 LV). Twenty (73%) patients had a normal sleep efficiency. Median apnoeas hypopnea index (IAH) was within normal range at 1.6 events/h (0, 14) events/hour. Only one patient had central sleep apnoeas, none had Cheyne-Stokes respiration, and 3 patients had an obstructive AHI between 5 and 10 events/hour. Optimal CPAP level decreased WOB (p = 0.05) and respiratory rate (p = 0.01).

CONCLUSIONS

Severe SDB was uncommon in children with CHF. However, CPAP may be beneficial by decreasing WOB and respiratory rate without deleterious effects on CI.

Midterm postoperative prognosis of patients with severe left heart valvular disease combined with moderate or severe pulmonary hypertension treated with treprostinil

BACKGROUND

To investigate the midterm postoperative prognosis of patients with severe left heart valvular disease combined with moderate or severe pulmonary hypertension (PAH) using subcutaneous injection of treprostinil.

METHODS

A retrospective study was conducted on 61 patients with severe left heart valvular disease combined with moderate or severe PAH who had undergone mechanical mitral and/or aortic valve replacement from April 2018 to October 2018. The patients were divided into the treprostinil group and the conventional treatment group according to whether they received treprostinil. The patients were assessed by SwanGanz catheterization, echocardiography, the 6-min walk test (6-MWT), the Borg dyspnoea score and the SF-36 questionnaire.

RESULTS

Compared with the preoperative data, the mPAP measured by SwanGanz catheterization, the results of the 6-MWT and the Borg score were significantly improved in both groups during the 1 year follow-up (P < 0.05). Regarding the comparison between the groups, the results in group T were significantly better than those in group C, including the results of the 6-MWT and the general health, vitality and mental health of SF-36 during the 1 year follow-up (P < 0.05).

CONCLUSIONS

Continuous subcutaneous infusion of treprostinil was not capable of decreasing pulmonary pressures in patients with severe left heart valvular disease combined with moderate or severe PAH during 1 year follow-up, although which some of our data suggest that might improve the symptoms and quality of life of these patients.

Cardiac manifestations and effects of enzyme replacement therapy for over 10 years in adults with the attenuated form of mucopolysaccharidosis type I

Background

Mucopolysaccharidosis type I (MPS I) is a rare autosomal recessive disease caused by a deficiency of the lysosomal enzyme α-L-iduronidase. Cardiac manifestations such as valvular heart disease are associated with poor prognosis. There have been only a few reports on the effect of long-term enzyme replacement therapy (ERT) for adult patients with the attenuated form of MPS I (Scheie syndrome) and cardiac involvement.

Methods

We retrospectively reviewed four adult patients of Scheie syndrome for which ERT was performed in our hospital. We investigated the findings of electrocardiography and echocardiography for the four patients performed before and 10 years after the initiation of ERT to evaluate the efficacy for ERT in Scheie syndrome.

Results

The ages of the patients at the initiation of ERT ranged from 26 to 46 years. The mean follow-up period was 129 months (121 to 134 months). Two patients underwent valve replacement surgery before the initiation of ERT. One patient had gradual progressive aortic valve stenosis and mitral valve stenosis during the course of ERT, and double valve replacement was finally performed. The patient who had started ERT at the youngest age did not develop significant cardiovascular disease. Regarding clinical courses with ERT for a period of 10 years, all four patients survived and they showed relatively stable cardiac conditions although two patients developed sick sinus syndrome after the valvular surgery.

Conclusions

Valvular disease in patients with Scheie syndrome occur at a young age. In a limited number of the four patients, ERT might contribute the stability of cardiac condition.

The role of endocarditis in sudden cardiac death: highlighting the value of the autopsy, pathological features and cardiac complications

OBJECTIVE

Endocarditis is increasing in incidence due to growing numbers of cardiac interventions, valve replacements and immunosuppressants. It can be difficult to diagnose clinically, has high mortality and can present as sudden cardiac death (SCD) with few/subtle preceding symptoms. True incidence of SCD related to endocarditis is unknown.

METHODS

Retrospective analysis of UK national database of 6000 cases of SCD, 1994-2020, for "endocarditis" as cause of death.

RESULTS

Of 30 cases (0.50%), 19(63%) were male and mean age was 36.2 ± 20.1 years. Postmortem examination showed the aortic valve was solely affected in 13 (43%), mitral in 9 (30%), tricuspid in 2(6.7%) and pulmonary in 1 (3.3%). Three cases (10%) had more than one valve affected and 2 (6.7%) were nonvalvular affecting the ascending aorta. Vegetations ranged from small easily missed irregularities to large fungating masses. Ten (33%) patients developed aortic abscesses, 2 of which had aneurysms, 13 (43%) had coronary artery septic emboli with micro-abscesses and myocardial microinfarction, and 2 (6.7%) were healed endocarditis with perforation and regurgitation with ventricular remodeling. Thirteen (43%) had an identifiable underlying valve abnormality or replacement, most common being a bicuspid aortic valve (7; 54%).

CONCLUSIONS

This study highlights that although rare, endocarditis is an important cause of SCD in those with normal valves, valvular disease and valve replacement surgery. Absence of a premortem diagnosis in 70% of our cohort highlights the need for detailed analysis of the heart and cardiac valves at autopsy. Gross appearance of vegetations varies widely and can be missed. Awareness of associated cardiac complications is required for elucidation of the cause of death and will provide valuable lessons for clinicians.

Color Doppler Splay: A Clue to the Presence of Significant Mitral Regurgitation

BACKGROUND

The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal "splay" of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign.

METHODS

Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR.

RESULTS

Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it.

CONCLUSIONS

The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.

Wearable devices can predict the outcome of standardized 6-minute walk tests in heart disease

Wrist-worn devices with heart rate monitoring have become increasingly popular. Although current guidelines advise to consider clinical symptoms and exercise tolerance during decision-making in heart disease, it remains unknown to which extent wearables can help to determine such functional capacity measures. In clinical settings, the 6-minute walk test has become a standardized diagnostic and prognostic marker. We aimed to explore, whether 6-minute walk distances can be predicted by wrist-worn devices in patients with different stages of mitral and aortic valve disease. A total of n = 107 sensor datasets with 1,019,748 min of recordings were analysed. Based on heart rate recordings and literature information, activity levels were determined and compared to results from a 6-minute walk test. The percentage of time spent in moderate activity was a predictor for the achievement of gender, age and body mass index-specific 6-minute walk distances (p < 0.001; R 2 = 0.48). The uncertainty of these predictions is demonstrated.

Aortic valve stenosis provides complementary information to bleeding risk scores in non-valvular atrial fibrillation patients initiating anticoagulation

BACKGROUND

The identification of modifiable bleeding risk factors may be of relevance. The aim is to evaluate if aortic stenosis (AS) provides additional information to bleeding risk scores for predicting major bleeding (MB) in non-valvular atrial fibrillation (AF).

METHODS

We designed a retrospective multi-center study including 2880 consecutive non-valvular AF patients initiating oral anticoagulation between January 2013 and December 2016. AS was defined as moderate or severe according to European echocardiography guidelines criteria. HASBLED, ATRIA and ORBIT scores were used to evaluate the bleeding risk. MB was defined according to the International Society on Thrombosis and Haemostasia criteria and registered at 18 months of follow-up.

RESULTS

168 (5.8%) patients had AS. Patients with AS had higher risk for MB compared to those without AS (HR = 2.13, 95% CI: 1.40-3.23, P < 0.001). Patients without AS and low-intermediate bleeding risk (0 points) showed the lowest MB rate, whereas the MB rate observed among patients with AS and high bleeding risk (2 points) was the highest one. Discrimination and reclassification analyses showed that AS provided additional information to bleeding risk scores for predicting MB at 18 months of follow-up.

CONCLUSIONS

In this population, AS was associated with an increased risk for MB at midterm follow-up. The three scoring systems showed a moderate discriminatory ability for MB. Moreover, the addition of AS was associated with a significant improvement in their predictive accuracy. We suggest that the presence of this valvulopathy should be taken into account for bleeding risk assessment.

The natural compound andrographolide inhibits human aortic valve interstitial cell calcification via the NF-kappa B/Akt/ERK pathway

Calcific aortic valve disease (CAVD) is caused by valve interstitial cells (VICs) initiating the thickening and calcification of valve leaflets. The present study aimed to investigate whether andrographolide (AGP) could attenuate the calcification of human valve interstitial cells (hVICs). hVICs stimulated by osteoblastic medium (OM) were treated with or without AGP. RNA sequencing was utilized to investigate changes in gene expression. Cell growth and calcification of hVICs were assessed using a CCK8 assay and Alizarin Red S staining, respectively. The expression of the two calcification-related markers, RUNX2 and ALP, were quantified by qRT-PCR, Western blotting, and immunofluorescent staining. The results indicate that hVICs treated with OM plus AGP exhibited decreased Alizarin Red S staining compared with cells treated with OM only in addition to down-regulation of ALP and RUNX2. Mappings of differentially expressed genes (DEGs) in different groups using Venn diagrams during analysis of gene expression profiles, 653 common DEGs were identified that displayed different biological functions and signaling pathways after treatment with AGP. RELA, a core factor of the NF-κB pathway was inhibited by AGP in addition to phosphorylation of AKT and ERK1/2. Thus, AGP attenuated calcification of hVICs. These results demonstrate that AGP, a promising natural product, can attenuate the process of CAVD.

Left-sided infective endocarditis in persons who inject drugs

PURPOSE

The purpose of this study was to describe left-sided infective endocarditis (LSIE) in persons who inject drugs (PWID) and compare that group to PWID with non-LSIE and to non-PWID with LSIE.

METHODS

Retrospective single-center study of adult IE patients from 2011 to 2018.

RESULTS

Of the 333 patients in our cohort, 54 were PWID with LSIE, 75 were PWID with non-LSIE, and 204 were non-PWID with LSIE. When comparing LSIE vs non-LSIE in PWID, the LSIE group was older (median age 35 vs 28.5, p < 0.01), had fewer S. aureus infections (59% vs 92%, p < 0.01), was more likely to have cardiac surgery (31% vs 13%, p < 0.01), and had a higher 10-week mortality (22% vs 5%, p < 0.01). When comparing PWID with LSIE to non-PWID with LSIE, the PWID group were younger (median age 35 vs 46, p < 0.01); had more frequent multi-valve involvement (33% vs 19%, p = 0.04), Staphylococcus aureus infections (54% vs 27%, p < 0.01), and previous IE (24% vs 8%, p < 0.01); and experienced more strokes (54% vs 31%, p < 0.01). Ten-week mortality was similar for LSIE in both PWID and non-PWID (24% vs 20%, p = 0.47).

CONCLUSIONS

LSIE in PWID is not uncommon. Compared to non-LSIE in PWID, valve surgery is more common and mortality is higher. For reasons that are unclear, stroke is more frequent in LSIE in PWID than in non-PWID with LSIE but mortality is no different.

Mucopolysaccharidosis type VI: case report with first neonatal presentation with ascites fetalis and rapidly progressive cardiac manifestation

BACKGROUND

The Mucopolysaccharidosis type VI (MPS VI), also known as Maroteaux-Lamy syndrome (OMIM 253200) is an autosomal recessive lysosomal disorder, caused by the deficiency of the enzyme N-acetylgalactosamine 4-sulfatase (also known as arylsulfatase B) due to mutations of the ARSB gene. Cardiologic features are well recognized, and are always present in MPS VI patients. Generally, the onset and the progression of the cardiologic symptoms are insidious, and just a few patients have developed a rapidly progressive disease. Cardiac involvement in MPS VI is a common and progressive feature. For MPS patients, cardiac evaluations are recommended every 1 to 2 years, including blood pressure measurement, electrocardiography and echocardiography. However, congestive heart failure and valvular surgical repair are not frequently seen, and if so, they are performed in adults. Here we report on an atypical MPS VI case with ascites fetalis and a rapidly progressive cardiac disease.

CASE PRESENTATION

A 6-month-old Brazilian male, only child of a Brazilian healthy non-consanguineous couple. During pregnancy, second trimester ultrasonography observed fetal ascites and bilateral hydrocele. Physical exam at 6 months-old revealed a typical gibbus deformity and MPS was suspected. Biochemical investigation revealed a diagnosis of MPS type VI, confirmed by molecular test. Baseline echocardiogram revealed discrete tricuspid regurgitation and a thickened mitral valve with posterior leaflet prolapse, causing moderate to severe regurgitation. The patient evolved with mitral insufficiency and congestive heart failure, eventually requiring surgical repair by the first year of age.

CONCLUSIONS

We report the first case of MPS VI whose manifestations started in the prenatal period with fetal ascites, with severe cardiac valvular disease that eventually required early surgical repair. Moreover, in MPS with neonatal presentation, including fetal hydrops, besides MPS I, IVA and VII, clinicians should include MPS VI in the differential diagnosis.

The Use of Echocardiography and Advanced Cardiac Ultrasonography During Pregnancy

PURPOSE OF REVIEW

Pregnancy is a time of significant cardiovascular change. Echocardiography is the primary imaging modality used to assess cardiovascular anatomy and physiology during pregnancy. Both two-dimensional (2D) echocardiography and advanced cardiac ultrasound modalities play pivotal roles in identifying and monitoring these changes, especially in women with preexisting or new cardiac disease. This paper reviews the role of echocardiography and advanced cardiac ultrasound during normal pregnancy and pregnancy complicated by hypertensive disorders, valvular disorders, and cardiomyopathy. It also examines the role of echocardiography in guiding decisions about delivery.

RECENT FINDINGS

The data establishing normal echo parameters during pregnancy are inconsistent. In addition, there is limited research exploring the role of advanced cardiac ultrasound modalities, such as tissue Doppler imaging or speckle tracking echocardiography, in assessing cardiac function during pregnancy. What data there are suggest that these advanced modalities can be used to identify subclinical changes before traditional echocardiography can, and thus have clear utility in identifying early abnormal cardiac responses to pregnancy. Echocardiography is the modality of choice for imaging the heart in pregnant women. Advanced ultrasound modalities increasingly play a role in identifying abnormal adaptations to pregnancy and detecting subclinical changes. This, in turn, can help promote a healthy pregnancy for both mother and fetus.

[Rehabilitation of valvular patient]

Valvular disease is the second indication of cardiac rehabilitation (CR) after coronary artery disease. Patients suffering valvular disease are addressed to CR after valvular repair, and are usually old. Valvular replacement are the most frequent, and more and more patients being treated by TAVI are addressed to CR. CR takes place on two phases: From the seventh (day 7) to the fifteenth (day 15) day: management of complications, respiratory physio, and help to autonomy if necessary. From the fifteenth day (day 15): rehabilitation to exercise after an exercise stress test with or without MVO₂ measurement. Because the patients are taking anticoagulants and are at risk of endocarditis, therapeutic education takes an important place during the stage. CR of patients suffering valvular disease has demonstrated its usefulness with: An increase of exercise capacity in all kind of valvular disease; A reduction of left ventricular hypertrophy in patients with aortic valve stenosis. No serious complication was observed in all studies regarding CR in patients with valvular disease.

Prevalence and Prognostic Implications of Valve Disease in Patients With Atrial Fibrillation Initiating Direct Oral Anticoagulants

INTRODUCTION AND OBJECTIVES

Valvular heart disease in patients with atrial fibrillation included in clinical trials with direct oral anticoagulants (DOAC) is common and is associated with worse prognosis. The aim of this study was to evaluate the prevalence of valvular heart disease and its influence on clinical events in real-world clinical practice.

METHODS

We conducted a retrospective multicenter registry including 2297 consecutive patients with nonvalvular atrial fibrillation initiating DOAC between January 2013 and December 2016. Valvular heart disease was defined as moderate or severe involvement. The primary study endopoint was the composite of death, stroke or transient ischemic attack/systemic embolism or major bleeding. A competing risks analysis was carried out using a Fine and Gray regression model, with death being the competing event.

RESULTS

A total of 499 (21.7%) patients had significant valvular heart disease. The most common form was mitral regurgitation (13.7%). Patients with valvular heart disease were older and had more comorbidities. After multivariable analysis, valvular heart disease was associated with a higher risk for the primary endpoint (HR, 1.54; 95%CI, 1.22-1.94; P<.001), death (HR, 1.44; 95%CI, 1.09-1.91, P=.010), and major bleeding (HR, 1.85; 95%CI, 1.23-2.79, P=.003), but there was no association with thromboembolic events (P >.05).

CONCLUSIONS

In patients with nonvalvular atrial fibrillation initiating DOACs, valvular heart disease is common and increases the risk of mortality, stroke, transient ischemic attack/systemic embolism, and major bleeding complications. These findings confirm the results of clinical trials and expand them to a real-life clinical setting.

Human cell-derived tissue-engineered heart valve with integrated Valsalva sinuses: towards native-like transcatheter pulmonary valve replacements

Transcatheter valve replacement indication is currently being extended to younger and lower-risk patients. However, transcatheter prostheses are still based on glutaraldehyde-fixed xenogeneic materials. Hence, they are prone to calcification and long-term structural degeneration, which are particularly accelerated in younger patients. Tissue-engineered heart valves based on decellularized in vitro grown tissue-engineered matrices (TEM) have been suggested as a valid alternative to currently used bioprostheses, showing good performance and remodeling capacity as transcatheter pulmonary valve replacement (TPVR) in sheep. Here, we first describe the in vitro development of human cell-derived TEM (hTEM) and their application as tissue-engineered sinus valves (hTESVs), endowed with Valsalva sinuses for TPVR. The hTEM and hTESVs were systematically characterized in vitro by histology, immunofluorescence, and biochemical analyses, before they were evaluated in a pulse duplicator system under physiological pulmonary pressure conditions. Thereafter, transapical delivery of hTESVs was tested for feasibility and safety in a translational sheep model, achieving good valve performance and early cellular infiltration. This study demonstrates the principal feasibility of clinically relevant hTEM to manufacture hTESVs for TPVR.

Valvular Disease in Marfan Syndrome: Surgical Considerations and Management

PURPOSE OF REVIEW

Detail the current strategies for the management of valve dysfunction in Marfan syndrome (MFS), understand the limitations of surgical interventions, and delineate the likely direction of future innovations.

RECENT FINDINGS

Significant advances in both medical and surgical management of MFS have been made over the last 50 years. This has resulted in improved overall outcomes. As MFS patients age, new clinical challenges that were once rare have emerged and can require complex care strategies. Medical management has seen advances and focuses on anti-impulse and molecular-based pharmacotherapy, along with close monitoring with serial imaging to minimize acute aortic dissection risk by selecting appropriate timing of prophylactic surgical intervention with increasing aortic dimensions. Ongoing trials are evaluating other potential drug therapies with the ultimate goal of targeted treatment. Over the last 50 years, significant advances have been made in the understanding and management of MFS. A move to prophylactic surgery for aortopathy and valve disease has progressed from a valve replacement to a valve-sparing strategy in many cases. However, the durability of these repairs is variable and the possibility of reintervention looms.

One-Year Follow-up After Tetralogy of Fallot Total Repair Preserving Pulmonary Valve and Avoiding Right Ventriculotomy

BACKGROUND

We reviewed our revised surgical strategy for tetralogy of Fallot (TOF) total correction to minimize early exposure to significant pulmonary regurgitation (PR) and to avoid right ventriculotomy (RV-tomy). Methods and Results: Since February 2016, we have tried to preserve, first, pulmonary valve (PV) function to minimize PR by extensive commissurotomy with annulus saving; and second, RV infundibular function by avoiding RV-tomy. With this strategy, we performed total correction for 50 consecutive patients with TOF until May 2018. We reviewed the early outcomes of 27 of 50 patients who received follow-up for ≥3 months. Mean patient age at operation was 10.2±5.0 months, and mean body weight was 8.8±1.2 kg. The preoperative pressure gradient at the RV outflow tract and the PV z-score were improved at most recent echocardiography from 82.0±7.1 to 26.8±6.4 mmHg, and from -2.35±0.49 to -0.55±0.54, respectively, during 11.1±1.6 months of follow-up after operation. One patient required re-intervention for residual pulmonary stenosis. Twenty-two patients had less than moderate PR (none, 1; trivial, 8; mild, 13), and 5 patients had moderate PR. There was no free or severe PR.

CONCLUSIONS

At 1-year follow-up, the patients who underwent total TOF correction with our revised surgical strategy had acceptable results in terms of PV function. The preserved PV had a tendency to grow on short-term follow-up.

Antiplatelet therapy in valvular and structural heart disease interventions

Transcatheter interventions for valvular and structural heart diseases are rapidly expanding due to greater operators' experience and development of new generation devices associated with increased procedural safety. They represent the standard strategy for patients with prohibitive risk for open surgery. These procedures are associated with a significant occurrence of both thrombotic and bleeding complications, thus in this setting, even more than in other percutaneous procedures, the balance between thrombotic and bleeding risk is critical. This review describes the current data available on the antithrombotic management of patients undergoing transcatheter aortic valve implantation (TAVI), percutaneous mitral valve repair with the MitraClip system, percutaneous left atrial appendage occlusion and percutaneous patent foramen ovale (PFO)/atrial septal defects (ASD) closure.

Early hemodynamic performance of the Trifecta™ surgical bioprosthesis aortic valve in Indian patient population: 12 month outcomes of the EVEREST post-market study

BACKGROUND

Indian patients undergoing surgical aortic valve replacement (SAVR) differ from western populations with respect to aortic annulus size and valve disease morphology. The purpose of this post-market, non-randomized observational study was to evaluate the early hemodynamic performance of the Trifecta™ bioprosthesis (Abbott, previously St. Jude Medical, Minneapolis, US) in an Indian patient population.

METHODS

From January 2014 to September 2015, 100 patients (mean age 64.4 ± 7.1 years, 62% male) undergoing SAVR for valve disease (68% stenosis, 7% insufficiency, 25% mixed pathology) were enrolled across 10 centers in India. Patients implanted with a 19-27 mm Trifecta™ valve were eligible to participate and were prospectively followed for 12-months post-implantation. Echocardiographic hemodynamic performance was evaluated at pre-implant, pre-discharge and at 12-months by an independent core laboratory. Adverse events were adjudicated by the study sponsor. Functional status at 12-months was assessed according to NYHA classification. Continuous data was summarized using descriptive statistics (mean &standard deviation,) and categorical data was summarized using frequencies and percentages.

RESULT

Ninety patients (mean age 64.5, 62.2% male) completed the 12-month follow up. Significant improvements in hemodynamic valve performance were reported in 81 patients with available echocardiographic data at 12 months. Compared to baseline at 12-month follow up visit, mean effective orifice area increased from 0.75cm² to 1.61cm² (p < 0.0001), mean pressure gradient reduced to 10.42 mmHg from 51.47 mmHg (p < 0.0001), cardiac output increased from 4.46 l/min to 4.85 l/min (P 0.9254). Compared to baseline, functional status improved by ≥1 NYHA class in 75% of patients at 12 months (95% Clopper-Pearson (Exact) confidence limit [64.6%, 83.6%]). No instances of early mortality (< 30 days from index procedure) or structural valve dysfunction were reported.

CONCLUSION

In an Indian patient population, implantation of the Trifecta™ bioprosthesis is shown to be safe and associated with favorable early hemodynamic performance and improved functional status at 12 months.

TRIAL REGISTRATION

The clinical study has been registered under Clinical Trial Registry-India ( http://www.ctri.nic.in ) and registration number is CTRI/2014/02/004434 registered on 25 February 2014 retrospectively registered.

Anesthetic Treatment of Cardiac Disease During Pregnancy

PURPOSE OF REVIEW

This review summarizes the pathophysiology, peripartum treatment, and anesthetic management of parturients with cardiac disease. Valvular disease, coronary disease, and cardiomyopathy are specifically addressed in the context of the normal physiologic changes of pregnancy. We offer recommendations for anesthetic approaches, hemodynamic goals with an emphasis on interdisciplinary planning between anesthesiologists, cardiologists, cardiothoracic surgeons, obstetricians, maternal fetal medicine specialists, and neonatologists.

RECENT FINDINGS

Vaginal delivery with neuraxial analgesia can be well tolerated by many pregnant patients with cardiac disease when coordinated by an interdisciplinary team of experts. Cardiac disease in pregnancy can present a significant challenge for the interdisciplinary care team. A detailed understanding of each patient's cardiac pathology and the physiologic changes of pregnancy are critical to ensure a safe and successful labor and delivery. Optimized medical therapy in the peripartum period and neuraxial anesthesia with the judicious use of vasoactive agents can be of great benefit for these parturients. As is generally the case, cesarean delivery should be primarily reserved for obstetric indications and maternal wellbeing, with careful consideration of the fetus to guide best practices.

Occult constrictive pericardial disease emerging 40 years after chest radiation therapy: a case report

Background

The main etiology of constrictive pericarditis (CP) has changed from tuberculosis to therapeutic mediastinal radiation and cardiac surgery. Occult constrictive pericardial disease (OCPD) is a covert disease in which CP is manifested in a condition of volume overload.

Case presentation

A 60-year-old patient with a history of thoracic radiation therapy for non-Hodgkin’s lymphoma (40 years earlier) was transferred to our hospital for treatment of repeated congestive heart failure. For a preoperative hemodynamic study, pre-hydration with intravenous normal saline (50 mL/hour) was used to manifest the pericardial disease and prevent contrast-induced nephropathy. The hemodynamic study showed a right ventricular dip-plateau pattern and discordance of right and left ventricular systolic pressures during inspiration, which was not seen in the volume-controlled state. These responses were concordant with OCPD. A pericardiectomy, aortic valve replacement, and mitral and tricuspid valve repair were performed. Postoperatively, the heart failure was controlled with standard medication.

Conclusions

This case revealed a volume-induced change in hemodynamics in OCPD with severe combined valvular heart disease, which suggests the importance of considering OCPD in patients who had undergone radiation therapy 40 years before.

Epidemiological trends of infective endocarditis in a single center in Italy between 2003-2015

OBJECTIVE

Changes in the incidence, clinical features and microbiology of infective endocarditis (IE) observed in a single center in Italy were compared between the period 2003-2010 and 2011-2015.

METHODS

All cases of IE, defined as definite or possible according to the modified Duke criteria, observed at the 'L. Sacco' Hospital in Milan, Italy between 2003 and 2015 were retrospectively reviewed.

RESULTS

366 episodes of IE were identified in 325 patients. The mean number of incident IE over the period 2003-2015 was 1.43 (range: 0.6-2.1) cases per 1000 admissions, with a significantly increasing trend from a mean of 1.28-1.72 cases per 1000 admissions/year in 2003-2010 and 2011-2015, respectively (+34%; p = .04). Staphylococci remain the leading pathogens causing IE (29%) with a relative increase of methicillin-resistant Staphylococcus aureus between the two periods. Streptococci and enterococci account for 26% and 18% of IE, respectively. We found an increase in the proportion of cases due to enterococci (from 14% in 2003-2010 to 22% in 2011-2015). The rate of in-hospital mortality was 19%, similar in the two periods studied.

CONCLUSION

The incidence of IE continuously increased in our cohort over the past decade and, along with the aging of the population, a raise in the incidence of health care-associated infections and a change in the distribution of prevalent pathogens were observed. Surgery was independently associated with higher in-hospital survival (AOR, 95% CI: 0.38, 0.19-0.74; p = .005). A constant surveillance is required to guide the optimal management of the changing epidemiology of IE.

Optimising the Haemodynamics of Aortic Valve-in-valve Procedures

Bioprosthetic surgical valves are increasingly implanted during cardiac surgery, instead of mechanical valves. These tissue valves are associated with limited durability and as a result transcatheter valve-in-valve procedures are performed to treat failed bioprostheses. A relatively common adverse event of aortic valve-in-valve procedures is residual stenosis. Larger surgical valve size, supra-annular transcatheter heart valve type, as well as higher transcatheter heart valve implantation depth, have all been shown to reduce the incidence of elevated post-procedural gradients. With greater understanding of technical considerations and surgical planning, valve-in-valve procedures could be more effective and eventually may become the standard of care for our increasingly ageing and comorbid population with failed surgical bioprostheses.

Pulmonary Valve Morphology in Patients with Bicuspid Aortic Valves

The aortic and pulmonary valve share a common developmental origin from the embryonic arterial trunk. Bicuspid aortic valve is the most common congenital anomaly and can occur isolated as well as in association with other congenital heart disease (CHD). Data on pulmonary valve morphology in these cases are scarce. In this study, we aimed to determine pulmonary valve morphology in hearts with BAV associated with CHD. In 83 post-mortem heart specimens with BAV and associated CHD, pulmonary valve morphology was studied and related to BAV morphology. In 14/83 (17%) hearts, the pulmonary valve was affected, bicuspid in 8/83 (10%), dome-shaped in 3/83 (4%) and atretic in 3/83 (4%). In specimens with a bicuspid pulmonary valve, 5/8 (63%) had a strictly bicuspid aortic valve (without raphe), 2/3 hearts (67%) with dome-shaped pulmonary valves and 2/3 hearts (67%) with atretic pulmonary valves had BAV without raphe. Six out of eight (75%) specimens with a bicuspid pulmonary valve had a perimembranous ventricular septal defect (VSD). 4/8 (50%) specimens with a bicuspid pulmonary valve were associated with chromosomal abnormalities: 3 (38%) had trisomy 18 and 1 (13%) had trisomy 13. In BAV with associated CHD, abnormal pulmonary valve morphology was observed in 17% of the hearts. The majority of hearts with abnormal pulmonary valve morphology had a Type B bicuspid aortic valve (without raphe). Bilateral semilunar valvular disease is associated with Type B BAVs and in many cases related to chromosomal abnormalities. As this study was performed in post-mortem specimens with high frequency of associated CHD, caution is warranted with application of these results to the general BAV population.

Congenital Double-Orifice Mitral Valve in Asymptomatic Patients

Congenital double-orifice mitral valve (DOMV) is a rare malformation that may affect both mitral valve and apparatus, and it is usually associated with other cardiac disorders. Asymptomatic DOMV is extremely rare. We present two similar cases of asymptomatic congenital double-orifice mitral valve. Both cases presented functionally normal mitral valve apparatus with two equally sized orifices, which were formed by a central fibrosis. In addition, final confirmatory diagnosis was made using three-dimensional (3D) echocardiography in both cases.