J. Pemberton

Characteristics and Outcomes for Right Heart Endocarditis: Six-year Cohort Study

Right heart endocarditis makes up 5-10% of all infective endocarditis involving valvular, congenital and artificial structures. Given the limited literature in this area, we reviewed the characteristics, management and outcomes of this condition in this retrospective cohort study. Thirty-five patients with right heart endocarditis admitted to Auckland City Hospital during 2005-2010 were followed-up for 3.4+/-2.5 years. In-hospital mortality was 11.4% (4), all occurring in those treated medically (20.0% (4) vs 0.0% (0), P=0.119). Surgical intervention was independently associated with reduced long-term mortality (HR 0.078, 95%CI 0.010-0.609, P=0.015) in multivariate analysis, while concurrent left heart endocarditis predicted both in-hospital mortality (HR 11.0, 95%CI 1.18-102, P=0.027) and long-term mortality (HR 3.20, 95%CI 1.03-9.92, P=0.044). Our study showed that surgical intervention and concomitant left heart endocarditis are positive and negative prognostic factors for outcomes after right heart endocarditis.

Valvular repair or replacement for mitral endocarditis: 7-year cohort study.

Background A few studies have compared mitral valve repair and replacement in the setting of infective endocarditis, with varying results. We compared the characteristics and outcomes of mitral repair and replacement in endocarditis patients. Methods All patients undergoing mitral valve repair or replacement for active mitral endocarditis during 2005–2011 were included. Operative and follow-up mortality, composite morbidity, recurrent endocarditis, and redo operations were prespecified endpoints for analyses. Results There were 25 and 35 patients undergoing mitral valve repair and replacement, respectively. They were followed-up for 3.9 ± 2.5 years. Valve replacement patients were older (p = 0.029), had a higher prevalence of intracardiac abscess (p = 0.035), previous endocarditis (p = 0.036), atrial fibrillation (p = 0.001), worse renal function (p = 0.013), higher risk scores (p = 0.004–0.020), and longer operation times (p < 0.001). Repair and replacement had similar rates of operative mortality (4.0% vs. 8.6%, p = 0.634), composite morbidity (16.0% vs. 28.6%, p = 0.357), survival (p = 0.564), recurrent endocarditis (p = 0.081), and redo operations (p = 0.813). Independent predictors of operative mortality were preoperative inotropic or intraaortic balloon pump support. The independent predictor of mortality during follow-up was dialysis. Independent predictors of composite morbidity were intracardiac abscess and hypercholesterolemia. The independent predictor of recurrent endocarditis was previous endocarditis, and the independent predictor of redo operation was previous stroke. Conclusion Mitral valve replacement candidates had more baseline risk factors and higher raw rates of postoperative mortality and morbidity, which did not reach statistical significance.

Severe Mitral Regurgitation Secondary to Dehiscence of a Mitral Annuloplasty Ring Shown on 3D Transoesophageal Echocardiography

T and a half years previously a 72 year-old man had undergone mitral valve repair and insertion of a 28mm-Cosgrove annuloplasty ring for severe symptomatic mitral regurgitation (MR). He had been admitted to hospital with mild symptoms of heart failure that resolved following surgery. TheMRwas due tomild leaflet thickening, prolapse of the middle scallop of the posterior mitral valve leaflet, and mitral annular dilation. The patient also

Relationship Between Diabetic Variables and Outcomes After Coronary Artery Bypass Grafting in Diabetic Patients

BACKGROUND Nearly half of the patients undergoing coronary artery bypass grafting (CABG) have diabetes. There is mixed data as to whether preoperative (haemoglobin A1c{HbA1c}) and/or perioperative diabetes control is associated with mortality and morbidity after CABG. We reviewed the characteristics and outcomes of diabetic patients undergoing CABG with a focus on HbA1c, perioperative glucose levels and diabetic treatment regimens. METHODS Diabetic patients undergoing CABG during July 2010 to June 2012 were studied (n=306). The last preoperative HbA1c levels, and perioperative glucose levels (mean and coefficient of variation {CV}) were retrospectively recorded, as well as the pre-existing and perioperative diabetes treatment regimens for analyses. RESULTS Mean HbA1c was 7.7+/-1.6%, and 11.1% (34), 56.2% (172), and 32.7% (100) of patients were managed preoperatively with diet only, oral diabetic medications and insulin respectively. For operative mortality which occurred in 2.0%, C-statistics (95% confidence interval) was only significant for HbA1c, 0.855 (0.757-0.975), and glucose CV on the day of surgery, 0.722 (0.567-0.877). HbA1c also detected postoperative renal failure, C-statistic 0.617 (0.504-0.730), but not other complications or mortality during follow-up. In multivariate analysis, HbA1c was the only diabetes-related independent predictor of operative mortality, hazards ratio 4.13 (1.04-16.4), and none of the diabetes-related variables predicted mortality during follow-up or other postoperative complications. CONCLUSION Preoperative HbA1c was the only diabetic variable to independently predict operative mortality after CABG, suggesting medium-term preoperative diabetes control is more important and prognostic of operative outcomes than perioperative diabetes control.

Eosinophilic myocarditis: characteristics, diagnostics and outcomes of a rare condition.

Eosinophilic myocarditis is a rare and potentially fatal condition characterised by eosinophilic inflammatory infiltration of myocardium. We report seven consecutive cases of eosinophilic myocarditis at our centre and discuss the important characteristics, investigation and management of this disease.

Right ventricular myxoma causing pulmonary outflow tract obstruction

A patient presented with shortness of breath, lethargy and weight loss. A computerized tomography and echocardiogram showed a mass in the right ventricle nearly obstructing the pulmonary valve during systole and prolapsing into the main pulmonary artery. The mass was completely excised. Histology was that of a typical myxoma.

Early or late surgery for endocarditis with neurological complications

Background The European Society of Cardiology 2015 guidelines advise urgent surgery for endocarditis complicated by cerebral embolism or transient ischemic events (1B evidence). Nevertheless, the timing of surgery remains contentious. This study aimed to review our experience of early versus delayed surgery in a selected cohort. Methods Our surgical database was examined for patients with a discharge diagnosis of endocarditis from 2005 to 2011. Selection was limited to patients who fulfilled the Duke criteria and underwent brain imaging for a clinically diagnosed preoperative neurological event. Patients were categorized as early surgery (≤7 days of clinical or cerebral imaging diagnosis of stroke) or delayed surgery (>7 days after diagnosis). Results Thirty-nine patients were identified: 20 in the early group (mean age 52 ± 15 years, diagnosis-to-surgery time 4 ± 2 days) and 19 in the delayed group (mean age 45 ± 15 years, diagnosis-to-surgery time 17 ± 11 days). There were no statistical differences in preoperative risks, operative data (cardiopulmonary bypass and crossclamp times) or postoperative neurological and mortality outcomes between the 2 groups. The size of the cerebral lesion was not a significant predictor of postoperative hemorrhagic or neurological outcome. Multivariate analysis did not show any independent predictor of mortality during follow-up (mean 51 ± 27 months). There was no difference in long-term survival, freedom from reoperation, or recurrent endocarditis between the 2 groups. Conclusions This study showed no statistical excess of mortality or neurological outcomes after early surgical intervention, regardless of the preoperative cerebral lesion size.

Calculation of left ventricular volume from 3D echocardiography: a comparison of three image analysis techniques

Left ventricular volume is an important clinical indicator for the diagnosis and the monitoring of treatment of many heart diseases. Automated quantification using echocardiography is challenging due to inherent image artefacts. In this paper, three different methods for calculating left ventricular volume were compared. 3D images of the left ventricle (LV) were reconstructed from rotationally acquired B-mode images for six patients at end-diastole and end-systole. By manual selection of the LV long-axis centre line, virtual, contiguous perpendicular short-axis images could be extracted. The LV wall was then detected by using (a) circle fitting, (b) smoothing between circles, and (c) greedy snake. Results of this study showed that there was no significant difference between chamber volume estimated by all three techniques.

Mapping the left ventricular cavity by analysis of images reconstructed from 3D trans-oesophageal echocardiography

Three dimensional measurement of the left ventricle (LV) has many clinical uses but is difficult to achieve. We present a new technique for automatic mapping of the LV cavity using images reconstructed from 3D trans-oesophageal echocardiography. 3D image sets were constructed from an angular sequence of conventional B-mode frames. Reconstructed 2D slices perpendicular to the LV axis were analysed to find the boundary of the LV cavity in each slice. 3D maps of the cavity were constructed by combining boundary positions from successive slices. Images from 3 patients were used to test the algorithm. Consistency was measured by analysing slice-to-slice differences in the boundary position and accuracy was measured by comparison with manual measurements by a cardiologist. Results of this preliminary study show that reconstruction and analysis of images perpendicular to the LV axis is a practical technique for mapping the LV cavity.

Propionibacterium acnes biofilm endocarditis requiring radical cardiac debridement and prosthetic valve replacements

transverse colon (Fig. 2). He underwent an uneventful right hemicolectomy and was released home after one week. At follow-up 14 days after his discharge, he was well and had regular bowel movements. Histopathology on the resected specimen showed moderately differentiated mucin producing colorectal adenocarcinoma, invading deeply into the muscularis, with 17 reactive lymph nodes. Colonic intussusception is an uncommon cause of bowel obstruction in adults accounting for only 1–5% of cases. Adult intussusception represents 5% of all cases of intussusception and is distinct from paediatric intussusception in its aetiology and treatment. In children, it is usually primary intussusception or secondary to a benign focus, and pneumatic or hydrostatic (air contrast enema) reduction of the intussusception is usually sufficient to treat the condition in 80% of cases. In contrast, almost 90% of cases in adults are secondary to a pathological condition that serves as a lead point, such as carcinomas, polyps, Meckel’s diverticulum, colonic diverticulum, strictures or benign neoplasms, which are usually diagnosed intraoperatively. Because of a significant risk of associated malignancy estimated at 65% of adult cases, radiological decompression should not be considered. Therefore, the great majority of adult cases of intussusception require definite surgical treatment. References