Cristina Sánchez-Enrique

Assessment of the diagnostic accuracy of 18 F-FDG PET/CT in prosthetic infective endocarditis and cardiac implantable electronic device infection: comparison of different interpretation criteria

PurposeThe diagnosis of prosthetic valve (PV) infective endocarditis (IE) and infection of cardiac implantable electronic devices (CIEDs) remains challenging. The aim of this study was to assess the usefulness of 18F-FDG PET/CT in these patients and analyse the interpretation criteria.MethodsWe included 41 patients suspected of having IE by the Duke criteria who underwent 18F-FDG PET/CT. The criteria applied for classifying the findings as positive/negative for IE were: (a) visual analysis of only PET images with attenuation-correction (AC PET images); (b) visual analysis of both AC PET images and PET images without AC (NAC PET images); (c) qualitative analysis of NAC PET images; and (d) semiquantitative analysis of AC PET images. 18F-FDG PET/CT was considered positive for IE independently of the intensity and distribution of FDG uptake. The gold standard was the Duke pathological criteria (if tissue was available) or the decision of an endocarditis expert team after a minimum 4 months follow-up.ResultsWe studied 62 areas with suspicion of IE, 28 areas (45 %) showing definite IE and 34 (55 %) showing possible IE. Visual analysis of only AC PET images showed poor diagnostic accuracy (sensitivity 20 %, specificity 57 %). Visual analysis of both AC PET and NAC PET images showed excellent sensitivity (100 %) and intermediate specificity (73 %), focal uptake being more frequently associated with IE. The accuracy of qualitative analysis of NAC PET images depended on the threshold: the maximum sensitivity, specificity and accuracy achieved were 88 %, 80 %, 84 %, respectively. In the semiquantitative analysis of AC PET images, SUVmax was higher in areas of confirmed IE than in those without IE (∆SUVmax 2.2, p < 0.001). When FDG uptake was twice that in the liver, IE was always confirmed, and SUVmax 5.5 was the optimal threshold for IE diagnosis using ROC curve analysis (area under the curve 0.71).ConclusionThe value of 18F-FDG PET/CT in the diagnosis of suspected IE of PVs and CIEDs is highly dependent on patient preparation and the method used for image interpretation. Based on our results, the best method is to consider a study positive for IE when FDG uptake is present in both AC PET and NAC PET images.

Risk score for cardiac surgery in active left-sided infective endocarditis

Objective To develop and validate a calculator to predict the risk of in-hospital mortality in patients with active infective endocarditis (IE) undergoing cardiac surgery. Methods Thousand two hundred and ninety-nine consecutive patients with IE were prospectively recruited (1996–2014) and retrospectively analysed. Left-sided patients who underwent cardiac surgery (n=671) form our study population and were randomised into development (n=424) and validation (n=247) samples. Variables statistically significant to predict in-mortality were integrated in a multivariable prediction model, the Risk-Endocarditis Score (RISK-E). The predictive performance of the score and four existing surgical scores (European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and II), Prosthesis, Age ≥70, Large Intracardiac Destruction, Staphylococcus, Urgent Surgery, Sex (Female) (PALSUSE), EuroSCORE ≥10) and Society of Thoracic Surgeons’s Infective endocarditis score (STS-IE)) were assessed and compared in our cohort. Finally, an external validation of the RISK-E in a separate population was done. Results Variables included in the final model were age, prosthetic infection, periannular complications, Staphylococcus aureus or fungi infection, acute renal failure, septic shock, cardiogenic shock and thrombocytopaenia. Area under the receiver operating characteristic curve in the validation sample was 0.82 (95% CI 0.75 to 0.88). The accuracy of the other surgical scores when compared with the RISK-E was inferior (p=0.010). Our score also obtained a good predictive performance, area under the curve 0.76 (95% CI 0.64 to 0.88), in the external validation. Conclusions IE-specific factors (microorganisms, periannular complications and sepsis) beside classical variables in heart surgery (age, haemodynamic condition and renal failure) independently predicted perioperative mortality in IE. The RISK-E had better ability to predict surgical mortality in patients with IE when compared with other surgical scores.

Cause and Long-Term Outcome of Cardiac Tamponade

Cardiac tamponade is a life-threatening condition, whose current specific cause and outcome are unknown. Our purpose was to analyze it. We performed a retrospective observational study with prospective follow-up data including 136 consecutive patients admitted with diagnosis of cardiac tamponade, from 2003 to 2013. We thoroughly recorded variables as clinical features, drainage/pericardiocentesis, fluid characteristics, and long-term events (new cardiac tamponade ± death). The median age was 65 ± 17 years (55% men). In the baseline characteristics, 70% were no smokers, 12% were on anticoagulation, and 13 had suffered a previous myocardial infarction. In the preceding month, 15 patients had undergone a cardiac catheterization, 5 cardiac surgery, and 5 pacemaker insertion. Fever was observed in 16% of patients and 21% displayed other inflammatory symptoms. In 81% of patients, pericardiocentesis was needed. The fluid was hemorrhagic or a transudate in the majority, with positive cytology in 15% and bacteria in 3.7%. Main causes were malignancy (32%), infection (24%), idiopathic (16%), iatrogenic (15%), postmyocardial infarction (7%), uremic (4%), and other causes (2%). After a maximum follow-up of 10.4 years, cardiac tamponade recurred in 10% of the cases (62% in the neoplastic group) and the 48% of patients died (89% in the neoplastic cohort). In conclusion, most cardiac tamponades are due to malignancy, having this specific cause a poorer outcome, probably as a manifestation of an advanced disease. The rest of causes, after an aggressive intensive management, have a good prognosis, especially the iatrogenic.

Usefulness of Thrombocytopenia at Admission as a Prognostic Marker in Native Valve Left-Sided Infective Endocarditis

In-hospital mortality of patients with infective endocarditis (IE) remains exceedingly high. Quick recognition of parameters accurately identifying high-risk patients is of paramount importance. The objective of this study was to analyze the incidence and severity of thrombocytopenia at presentation and its prognostic impact in patients with native valve left-sided IE. We studied a cohort of 533 consecutive episodes of native valve left-sided IE prospectively recruited. We distinguished 2 groups: group I (n = 175), episodes who had thrombocytopenia at admission, and group II (n = 358) gathered all the episodes who did not. Thrombocytopenia at admission was defined as a platelet count of <150,000/μl. No differences were found in the need for surgery, but in-hospital mortality was significantly higher in patients with thrombocytopenia (p <0.001). Mortality rate was associated with the degree of thrombocytopenia (p <0.001). In the multivariable analysis, thrombocytopenia at admission was an independent predictor of higher mortality (p = 0.002). A synergistic interaction between thrombocytopenia and Staphylococcus aureus on mortality risk was also observed (p = 0.04). In conclusion, thrombocytopenia at admission is an early risk marker of increased mortality in patients with native valve left-sided IE. Mortality rates increased with increasing severity of thrombocytopenia. Thrombocytopenia at admission should be used as an early marker for risk stratification in patients with native valve IE to identify those at risk of complicated in-hospital evolution and increased mortality.

Streptococcus bovis endocarditis: Update from a multicenter registry.

BACKGROUND Infective endocarditis (IE) due to Streptococcus bovis has been classically associated with elderly patients, frequently involving >1 valve, with large vegetations and high embolic risk, which make it a high-risk group. Our aim is to analyze the current clinical profile and prognosis of S bovis IE episodes, in comparison to those episodes caused by viridans group streptococci and enterococci. METHODS We analyzed 1242 consecutive episodes of IE prospectively recruited on an ongoing multipurpose database, of which 294 were streptococcal left-sided IE and comprised our study group. They were classified into 3 groups: group I (n = 47), episodes of IE due to S bovis; group II (n = 134), episodes due to viridans group streptococci; and group III (n = 113), those episodes due to enterococci. RESULTS The incidence of enterococci IE has significantly increased in the last 2 decades (6.4% [1996-2004] vs 11.1% [2005-2013]; P = .005), whereas the incidence of IE due to S bovis and viridans streptococci have remained stable (4% and 10%, respectively). Gender distribution was similar in the 3 groups. Patients with S bovis and enterococci IE were older than those from group II. Nosocomial acquisition was more frequent in group III. Concerning comorbidity, diabetes mellitus (36.7% vs 9.2% vs 26.8%; P < .001) was more common in groups I and III. Chronic renal failure was more prevalent in patients from group III (4.2% vs 1.5% vs 19%; P < .001). Prosthetic valve IE was more frequent in enterococcal IE. Infection upon normal native valves was more frequent in S bovis IE. Colorectal tumors were found in 69% of patients from this group. Vegetation detection was similar in the 3 groups. However, vegetation size was smaller in S bovis IE. During hospitalization, in-hospital complications and in-hospital mortality were higher in enterococci episodes. CONCLUSIONS S bovis IE accounts for 3.8% of all IE episodes in our cohort; it is associated with a high prevalence of colonic tumors, with predominance of benign lesions, and affects patients without preexisting valve disease. It is related to small vegetations and a low rate of in-hospital complications, including systemic embolisms. In-hospital mortality is similar to that of viridans group streptococci.

Usefulness of New-Onset Atrial Fibrillation, as a Strong Predictor of Heart Failure and Death in Patients With Native Left-Sided Infective Endocarditis.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and has been independently related to increased morbidity and mortality. AF is a frequent arrhythmia in infective endocarditis (IE). Nevertheless, there are no data on how AF affects the clinical outcome of patients with endocarditis. Our purpose was to investigate patient characteristics, microbiology, echocardiographic findings, in-hospital course, and prognosis of patients with IE who develop new-onset AF (NAF) and compare them with those who remained in sinus rhythm (SR) or had previous AF (PAF). From 1997 to 2014, 507 consecutive patients with native left-sided IE were prospectively recruited at 3 tertiary care centers. We distinguished 3 groups according to the type of baseline heart rhythm during hospitalization and previous history of AF: NAF group (n = 52), patients with no previous history of AF and who were diagnosed as having NAF during hospitalization; SR group (n = 380), patients who remained in SR; and PAF group (n = 75), patients with PAF. Patients with NAF were older than those who remained in SR (68.3 vs 59.6 years, p <0.001). At admission, heart failure was more common in NAF group (53% vs 34.3%, p <0.001), whereas stroke (p = 0.427) was equally frequent in all groups. During hospitalization, embolic events occurred similarly (p = 0.411). In the multivariate analysis, NAF was independently associated with heart failure (odds ratio 3.56, p <0.01) and mortality (odds ratio 1.91, p = 0.04). In conclusion, the occurrence of NAF in patients with IE was strongly associated with heart failure and higher in-hospital mortality independently from other relevant clinical variables.

Pacemaker lead endocarditis assessed by a multimodality imaging approach.

A 75-year-old man with a permanent DDD pacemaker implanted 3 years ago was admitted to our hospital with 1 month history of low-grade fever and chills. Blood cultures were positive for Staphylococcus schleiferi . Transthoracic echocardiography revealed a large right atrial mass attached to the pacemaker lead, highly suspicious of being …

Usefulness of 18F Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Infective Endocarditis in Daily Practice

Positron emission tomography/computed tomography (PET/CT) is helpful in prosthetic valve (PV) infective endocarditis (IE), but its usefulness in other settings is less established [(1)][1]. We aim to evaluate the yield of PET/CT in patients with suspicion of IE in 3 scenarios: PV, native valves (NV

Mitral paravalvular leak generating a Coanda effect inside the left atrium appendage

We present the case of a 40-year-old female with previous history of mitral valve replacement due to a mitral stenosis. Nine months later underwent an emergent prosthetic valve replacement due to prosthetic valve thrombosis. On followup transoesophageal echocardiogram revealed a severe mitral paravalvular leak (PVL) situated in the anterior mitral annulus, producing an eccentric jet going through left atrial wall and reaching the left atrial roof (Panel A, see Supplementary material online, Video I). Live three-dimensional color Doppler echocardiography was performed, which improved the spatial assessment of the leak, including direct en face visualization from the left atrium, and showing that the leak involved the anterior mitral annulus from the aortic root to the left atrial appendage (LAA) (Panel B, see Supplementary material online, Video II). The transoesophageal views of LAA disclosed that the regurgitant jet impacted with the Marshall ligament which divided it in two jets, the one following the left atrial wall and another one entering inside the LAA, along its wall causing a ‘‘Coanda effect’’ inside the LAA. (Panels C, D, E and F, see Supplementary material online, Videos II and III) (Fig. 1).