Cristina Fernández

Risk of embolization after institution of antibiotic therapy for infective endocarditis.

OBJECTIVES This study was designed to assess the risk of systemic embolization in patients with left-sided infective endocarditis, once adequate antibiotic treatment had been initiated, on the basis of prospective clinical follow-up. BACKGROUND As one of the complications of infective endocarditis, embolization has a great impact on prognosis. Prediction of an individual patients risk of embolization is very difficult. METHODS We studied 217 episodes of left-sided endocarditis that were experienced among a cohort of 211 prospectively recruited patients. According to the Duke criteria, 91% of the episodes were definite infective endocarditis. Seventy-two episodes involved infections located on prosthetic valves. All patients were studied by transthoracic and transesophageal echocardiography. Clinical, echocardiographic and microbiologic data were entered in a data base. The mean follow-up interval was 151 days. RESULTS Twenty-eight episodes (12.9%; group I) of endocarditis had embolic events after the initiation of antibiotic therapy. The remaining 189 episodes did not embolize (group II). Most emboli (52%) affected the central nervous system, and 65% of the embolic events occurred during the first two weeks after initiation of antibiotic therapy. Previous embolism was associated with new embolism (relative risk [RR] 1.73, 95% confidence interval [CI] 1.02 to 2.93; p = 0.05). There was an increase in the risk of embolization with increasing vegetation size (RR 3.77, 95% CI 0.97 to 12.57; p = 0.07). Vegetation size had no impact on the risk of embolization in streptococcal endocarditis or aortic infection. By contrast, large (> or = 10 mm) vegetations had a higher incidence of embolism when the microorganism was staphylococcus (p = 0.04) and the mitral valve was infected (p = 0.03). The increase in vegetation size at follow-up showed a higher risk for embolization (RR 2.64, 95% CI 0.98 to 7.16; p = 0.02). CONCLUSIONS Embolism before antimicrobial therapy is a risk factor for new emboli. The risk of embolization seems to increase with increasing vegetation size, and this is particularly significant in mitral endocarditis and staphylococcal endocarditis. An increase in vegetation size, despite antimicrobial treatment, may predict later embolism.

Periannular extension of infective endocarditis

OBJECTIVES This prospective study was designed to assess the current clinical course, risk factors, microbiologic profile and echocardiographic findings of patients with left-sided endocarditis and perivalvular complications. BACKGROUND Periannular complications worsen the prognosis of patients with endocarditis. The relation between these complications and the clinical and microbiologic data has not been clearly defined. METHODS In this clinical cohort study, 211 patients with left-sided endocarditis, according to the Duke criteria, were prospectively recruited. All patients underwent conventional and transesophageal echocardiography. The mean follow-up interval was 151 days. RESULTS Perivalvular complications were detected in 78 patients (37%). The incidence of periannular extension of infection in native and prosthetic valves was 29% and 55%, respectively. The presence of prosthesis (relative risk [RR] 1.88, 95% confidence interval [CI] 1.35 to 2.64) and previous endocarditis (RR 1.78, 95% CI 1.16 to 2.7) were the only pre-existing heart conditions associated with perivalvular complications. Aortic infection (RR 1.8, 95% CI 1.23 to 2.66) and the development of atrioventricular (AV) block (RR 2.55, 95% CI 1.91 to 3.41) were related with the existence of these complications. Coagulase-negative staphylococci were very common in patients with perivalvular complications (RR 1.77, 95% CI 1.21 to 2.59), and small vegetations were more frequent in these patients (RR l.45, 95% CI 0.95 to 2.22). An operation was more frequently performed in patients with perivalvular complications, but mortality was similar in patients with and without these complications. CONCLUSIONS Aortic infection, prosthetic endocarditis, new AV block and coagulase-negative staphylococci were independent risk factors of periannular complications. The period between symptom onset and diagnosis, the incidence of pericardial effusion and persistent signs of infection were similar between patients with and without perivalvular complications. Patients with perivalvular complications did not demonstrate a difference in the presence or size of vegetations or the frequency of embolism. An operation was more frequently performed in these patients, but mortality was similar in both groups.

Fate of stent-related side branches after coronary intervention in patients with in-stent restenosis

OBJECTIVES We sought to assess the fate of stent (ST)-related side branches (SB) after coronary intervention in patients with in-ST restenosis. BACKGROUND In-ST restenosis constitutes a therapeutic challenge. Although the fate of lesion-related SB after conventional angioplasty or initial coronary stenting is well established, the outcome of ST-related SB in patients with in-ST restenosis undergoing repeat intervention is unknown. METHODS One hundred consecutive patients (age 61 +/- 11 years, 22 women) undergoing repeat intervention for in-ST restenosis (101 ST) were prospectively studied. Two hundred and twenty-six SB spanned by the ST were identified. The SB size, type, ostium involvement, location within the ST and take-off angle were evaluated. The SB TIMI (Thrombolysis in Myocardial Infarction trial) flow grade was studied in detail before, during, immediately after the procedure, and at late angiography. RESULTS Occlusion (TIMI flow grade = 0) was produced in 24 (10%) SB, whereas some degree of flow deterioration (> or = 1 TIMI flow grade) was observed in 57 SB (25%). The SB occlusion was associated with non-Q wave myocardial infarction in two patients (both had large and diseased SB). Side-branch occlusion at the time of initial stenting (RR [relative risk] 11.1, 95% CI [confidence interval] 3.5-35.5, p < 0.001), diabetes (RR 3.5, 95% CI 1.1-10.5, p = 0.02), SB ostium involvement (RR 5.0, 95% CI 1.4-17.2, p = 0.004), baseline SB TIMI flow grade <3 (RR 5.5, 95% CI 1.7-18.1, p = 0.005), and restenosis length (RR 1.05 95% CI 1.01-1.11, p = 0.03) were identified as independent predictors of SB occlusion. Late angiography in 19 initially occluded SB revealed that 17 (89%) were patent again. The long-term clinical event-free survival (81% vs. 82% at two years) in patients with and without initial SB occlusion was similar. CONCLUSIONS Occlusion or flow deterioration of SB spanned by the ST is relatively common during repeat intervention for in-ST restenosis. Several factors (mainly anatomic features) are useful predictors of this event. However, most SB occlusions are clinically silent and frequently reappear at follow-up.

Initial Results and Long-Term Clinical and Angiographic Outcome of Coronary Stenting in Women

To assess whether gender influences the results of coronary stenting, 158 consecutive women undergoing coronary stenting were compared with 823 consecutive men. Women had more adverse baseline characteristics, a higher hospital mortality, and were independently associated with procedural failure/complications (relative risk 2.4, 95% confidence interval 1.2 to 4.8); however, the long-term event-free survival and the restenosis rate were not influenced by gender.

Clinical impact and evolution of mitral regurgitation following transcatheter aortic valve replacement: a meta-analysis

Objectives Mitral regurgitation (MR) is a common entity in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but its influence on outcomes remains controversial. The purpose of this meta-analysis was to assess the clinical impact of and changes in significant (moderate–severe) MR in patients undergoing TAVR, overall and according to valve design (self-expandable (SEV) vs balloon-expandable (BEV)). Methods All national registries and randomised trials were pooled using meta-analytical guidelines to establish the impact of moderate–severe MR on mortality after TAVR. Studies reporting changes in MR after TAVR on an individual level were electronically searched and used for the analysis. Results Eight studies including 8015 patients (SEV: 3474 patients; BEV: 4492 patients) were included in the analysis. The overall 30-day and 1-year mortality was increased in patients with significant MR (OR 1.49, 95% CI 1.16 to 1.92; HR 1.32, 95% CI 1.12 to 1.55, respectively), but a significant heterogeneity across studies was observed (p<0.05). The impact of MR on mortality was not different between SEV and BEV in meta-regression analysis for 30-day (p=0.360) and 1-year (p=0.388) mortality. Changes in MR over time were evaluated in nine studies including 1278 patients. Moderate–severe MR (SEV: 326 patients; BEV: 192 patients) improved in 50.5% of the patients at a median follow-up of 180 (30–360) days after TAVR, and the degree of improvement was greater in patients who had received a BEV (66.7% vs 40.8% in the SEV group, p=0.001). Conclusions Concomitant moderate–severe MR was associated with increased early and late mortality following TAVR. A significant improvement in MR severity was detected in half of the patients following TAVR, and the degree of improvement was greater in those patients who had received a BEV.

Vegetation size at diagnosis in infective endocarditis: influencing factors and prognostic implications.

The role of vegetation as the key feature of infective endocarditis is universally recognized. Nowadays, the wide availability of transesophageal echocardiography has made of it the most employed technique to establish the diagnosis by visualizing vegetations. However, the factors which influence the size of vegetation when first detected are not clearly determined. Furthermore, there is considerable controversy regarding the prognostic implications of the size of vegetation. This is of paramount significance to early identify patients at high risk for complications, which might benefit from aggressive attitudes. We present a study based on TEE. Our results show that the size of vegetation at admission is mostly determined by anatomical and not microbiological factors, and the prognostic influence of vegetations on the risk of embolisms, need of surgery, persistent infection and septic shock.

Impact of Intravenous Lysine Acetylsalicylate Versus Oral Aspirin on Prasugrel-Inhibited Platelets Results of a Prospective, Randomized, Crossover Study (the ECCLIPSE Trial)

Background—Prasugrel and ticagrelor, new P2Y12-adenosine diphosphate receptor antagonists, are associated with greater pharmacodynamic inhibition and reduction of cardiovascular events compared with clopidogrel in patients with an acute coronary syndrome. However, evidence is lacking about the effects of achieving faster and stronger cyclooxygenase inhibition with intravenous lysine acetylsalicylate (LA) compared with oral aspirin on prasugrel-inhibited platelets. Methods and Results—This was a prospective, randomized, single-center, open, 2-period crossover platelet function study conducted in 30 healthy volunteers. Subjects were randomly assigned to receive a loading dose of intravenous LA 450 mg plus oral prasugrel 60 mg or loading dose of aspirin 300 mg plus prasugrel 60 mg orally in a crossover fashion after a 2-week washout period between treatments. Platelet function was evaluated at baseline, 30 minutes, 1 h, 4 h, and 24 h using light transmission aggregometry and vasodilator-stimulated phosphoprotein phosphorylation. The primary end point of the study, inhibition of platelet aggregation after arachidonic acid 1.5 mmol/L at 30 minutes, was significantly higher in subjects treated with LA compared with aspirin: 85.3% versus 44.3%, respectively, P=0.003. This differential effect was observed at 1 hour (P=0.002) and 4 hours (P=0.048), but not at 24 hours. Subjects treated with LA presented less variability and faster and greater inhibition of platelet aggregation with arachidonic acid compared with aspirin. Conclusions—The administration of intravenous LA resulted in a significant reduction of platelet reactivity compared with oral aspirin on prasugrel-inhibited platelets. Loading dose of LA achieves an earlier platelet inhibition and with less variability than aspirin. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02243137.

Comparación entre la eco-dobutamina y talio-201 SPECT reposo-redistribución en la valoración de la viabilidad miocárdica considerando el PET como patrón oro

Introduccion y objetivos Comparar la gammagrafia con talio-201 SPECT reposo-redistribucion y la ecocardiografia con dobutamina para detectar miocardio viable en pacientes con disfuncion ventricular izquierda severa utilizando las imagenes metabolicas de la tomografia por emision de positrones como referencia estandar. Material y metodo A 25 pacientes con enfermedad coronaria severa y disfuncion ventricular se les realizo un ecocardiograma con dobutamina desde 5 hasta 40 mg/kg/min en estadios de 3 min, y una gammagrafia SPECT talio-201 siguiendo el protocolo reposo-redistribucion con imagenes tardias a las 4 h. La captacion de 18-fluordesoxiglucosa por tomografia por emision de positrones fue el patron oro. Los criterios de viabilidad fueron: para el talio-201, presencia de redistribucion en las imagenes tardias y captacion normal; para la ecocardiografia con dobutamina: mejoria mantenida del movimiento regional y la respuesta bifasica. Resultados La sensibilidad para la redistribucion de talio fue del 46%, para la captacion normal mas redistribucion del 82%, del 34% para la respuesta bifasica y del 58% en la respuesta bifasica mas mantenida de la dobutamina. La especificidad de la respuesta bifasica fue del 82 y 67% para la redistribucion. En el analisis de regresion logistica los mejores resultados fueron para la respuesta bifasica (OR; IC del 95%): 2,01 (1,10-3,99) y la captacion normal de talio mas segmentos con redistribucion 2,68 (1,42-5,13). Estos resultados fueron similares cuando se analizaron ambas tecnicas conjuntamente. Conclusiones La respuesta bifasica de la ecocardiografia con dobutamina y la captacion normal de talio-201, sumada a los segmentos con redistribucion tardia, fueron los mejores predictores de viabilidad.

Letter by Alfonso et al Regarding Article, “Paclitaxel-Coated Balloon Catheter Versus Paclitaxel-Coated Stent for the Treatment of Coronary In-Stent Restenosis”

To the Editor: We read with great interest the elegant randomized study by Unverdorben et al1 comparing paclitaxel-eluting balloons (PB) (66 patients) with paclitaxel-eluting stents (65 patients) in patients with bare-metal in-stent restenosis. The authors should be commended for their important article confirming the unique efficacy of PB in this challenging anatomic scenario. Some issues, however, deserve consideration. First, the primary end point of the study was the angiographic late loss at 6 months. Patients allocated to the PB group had a significantly lower late loss than those in the paclitaxel-eluting stent …