18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Surgical Management and Outcomes of Cardiac and Great Vessels Echinococcosis: A 16-Year Experience

BACKGROUND

Cardiac involvement is an uncommon presentation of hydatid disease. In this study, we aim to analyze the experience of surgical treatment of cardiac and great vessels echinococcosis in our cardiovascular and thoracic surgery department.

METHODS

Through a 16-year period, from 2000 to 2015, 27 patients underwent surgery for cardiac and great vessels hydatid disease. The clinical, operative, and postoperative data were analyzed through this retrospective and descriptive study.

RESULTS

Most of our patients came from a rural area. The most common symptom was chest pain. The diagnosis was mainly made by transthoracic echocardiography, which has shown the right ventricle as the most frequent location of the disease. All patients received surgical treatment under cardiopulmonary bypass, and only six surgeries were performed without cross-clamping the aorta. Inhospital mortality rate was 7.4%.

CONCLUSIONS

Cardiac hydatidosis is a rare but potentially serious condition whose treatment is mainly surgical even for asymptomatic patients owing to its possible fatal complications. The surgery outcomes are usually satisfactory. Follow-up examinations are highly recommended to detect recurrences.

Fungal infections of the heart: A clinicopathologic study of 50 autopsy cases

Cardiac fungal infection (CFI) is relatively uncommon, but its incidence is increasing. It is associated with a grim prognosis, but some CFI patients can survive given an early diagnosis and aggressive therapy. To clarify the clinicopathologic features of CFI, a retrospective autopsy study was conducted. Among a total of 4396 autopsy cases collected over a 33-year period (1973-2005), 50 CFI patients (1.1%) were selected and studied clinicopathologically. The study subjects were 32 males and 18 females with a mean age of 65.5 years. Underlying diseases for CFI included solid malignant neoplasms (n=23), hematologic disorders (n=10), chronic renal diseases (n=7), liver diseases (n=5), diabetes mellitus (n=5), and other miscellaneous ailments. Antibiotics were given to 47 patients, while corticosteroids, antineoplastic drugs, and antifungal agents were used for 21, 12, and 12 patients, respectively. None of the patients was diagnosed to have CFI antemortem. Most patients (n=45) demonstrated multi-organ fungal infections with myocardial involvement. Causative pathogens were Candida (n=36), Aspergillus (n=9), Mucor (n=4), and Cryptococcus (n=1). Comparisons between previous CFIs (1973-1989) and recent CFIs (1990-2005) revealed an increasing proportion of non-candidal CFIs (p=0.004) in the latter. Our results point to the clinical importance of defining diagnostic criteria and therapeutic strategies for CFIs, especially for non-candidal CFIs.

Myocarditis

Myocarditis represents a heterogeneous final common pathway for myocardial inflammation of diverse etiologies and accounts for up to one-third of cases of dilated cardiomyopathy. The pathophysiology of viral myocarditis can be disaggregated into the effects of direct viral mediated injury, triggered acute and chronic autoimmune responses, and subsequent adverse remodeling. Recent research highlights the pathogenic role of persistent viral genome expression, Fas-ligand, tumor necrosis factor-alpha receptor 1, and antimyosin autoantibodies in the evolution of chronic systolic and diastolic heart failure. Recent refinements in endomyocardial biopsy evaluation, cardiac magnetic resonance imaging, and cytokine assays augment existing diagnostic modalities. Novel specific immunosuppressive targets aimed at interrupting myocyte injury and apoptosis, including interferon-beta seem promising to date in small clinical studies performed on selected patients.

Pericardial tamponade masquerading as septic shock

A 53-year-old man with steroid dependent rheumatoid arthritis presented with fever and serous articular drainage. Oral antibiotics were initially prescribed. Subsequent hemodynamic instability was attributed to septic shock. Further evaluation revealed a pericardial effusion with tamponade. Pericardiocentesis of purulent fluid promptly corrected the hypotension. Proteus mirabilis was later isolated from both the infected joint and the pericardial fluid. This is the first report of combined Proteus mirabilis septic arthritis and purulent pericarditis. It documents the potential for atypical transmission of Gram-negative pathogens, to the pericardium, in patients with a high likelihood of preexisting pericardial disease. In immunocompromised patients, the typical signs and symptoms of pericarditis may be absent, and the clinical presentation of pericardial tamponade may be misinterpreted as one of septic shock. This case underscores the value of a careful physical examination and proper interpretation of ancillary studies. It further illustrates the importance of initial antibiotic selection and the need for definitive treatment of septic arthritis in immunocompromised patients.

Bacterial pericarditis and tamponade due to nonencapsulated Haemophilus influenzae complicating a case of adult community-acquired pneumonia

We report a case of bacterial pericarditis in an immunologically competent adult female caused by nonencapsulated Haemophilus influenzae (H influenzae) that was complicated by the acute development of life-threatening pericardial tamponade. H influenzae is a gram-negative coccobacillus, a pathogen most frequently associated with childhood exanthema (otitis media, meningitis) and, less frequently, adult pneumonia. Encapsulated, type b, or typable H influenzae is the strain implicated in childhood infections. On the other hand, nonencapsulated or nontypable H influenzae is the specific strain most often associated with exacerbation of chronic obstructive airway disease. Bacterial pericarditis caused by either subtype of H influenzae is exceedingly rare. We have located only 15 previously reported cases of H influenzae pericarditis occurring in adults in the world medical literature, the majority of which date back to the pre-antibiotic era. In 12 of these 15 cases (the only cases in which typing could be accomplished), the encapsulated strain of H influenzae was cultured from the pericardial fluid. Thus, to the best of our knowledge, we are reporting here the first case of bacterial pericarditis caused by nonencapsulated H influenzae in an immunologically competent adult.

Purulent pericarditis caused by group a streptococcus

Purulent pericarditis is a rare disease that is most often caused by organisms such as Staphylococcus aureus, Streptococcus pneumoniae, viridans streptococci, Haemophilus influenzae, and anaerobic bacteria. We present an unusual case of purulent pericarditis caused by Streptococcus pyogenes, Lancefield group A streptococcus (GAS), and we provide a review of the literature.