Jennifer Cautela

Diagnostic yield of FDG positron-emission tomography/computed tomography in patients with CEID infection: a pilot study

AIMS Whole body imaging with (18)F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG PET/CT) has proven useful in various infectious diseases. The purpose of this pilot study was to assess the diagnostic yield of FDG PET/CT in patients with cardiac implantable electronic device (CIED) infection. METHODS AND RESULTS A total of 21 patients with CIED infection were prospectively included. Diagnosis of CIED infection was made in accordance with current criteria. It was classified in three categories, i.e. superficial skin infection, pocket site infection, or cardiac device-related infective endocarditis (CDRIE). All patients underwent FDG PET/CT. Scans were interpreted blindly, i.e. without prior knowledge of diagnosis, by experienced nuclear medicine physicians. The accuracy of FDG PET/CT was assessed for each diagnostic category. Findings demonstrated superficial skin infection in 1 patient, pocket site infection in 15, and CDRIE in 13 (definite: 7; possible: 6). In patients with pocket site infection, the sensitivity and specificity of FDG PET/CT were 86.7% [59.5-98.3, 95% confidence interval (CI)] and 100% [42.1-100, 95% CI]. The only patient with superficial skin infection was accurately identified by FDG PET/CT. The sensitivity and specificity of FDG PET/CT in patients with CDRIE were 30.8% [9.1-61.4, 95% CI] and 62.5% [24.5-91.5, 95% CI]. Most false-negative results occurred in patients who had undergone previous antimicrobial treatment. CONCLUSION This study indicates that FDG PET/CT is highly accurate for the diagnosis of skin and pocket CIED infection but low for infective endocarditis. This suggests that the reliability of FDG PET/CT findings in management decision making varies according to the type of CIED infection.

Infective Endocarditis: Prevention, Diagnosis, and Management

Infective endocarditis (IE) is among the most severe infectious disease, the prevention of which has not decreased its incidence. The age of patients and the rate of health care-associated IE have increased as a consequence of medical progress. The prevention strategies have been subjected to an important debate and nonspecific hygiene measures are now placed above the use of antibiotic prophylaxis. Indeed, the level of evidence of antibiotic prophylaxis efficiency is low and the indications of its prescription have been restricted in the recent international guidelines. In cases carrying a high suspicion of IE, efforts should be made to rapidly identify patients with a definite or highly probable diagnosis of IE and to find the causative pathogen to ensure that appropriate treatment, including urgent valvular surgery, begins promptly. Although echocardiography remains the main accurate imaging modality to identify endocardial lesions associated with IE, it can be negative or inconclusive especially in cases of prosthetic valve or other intracardiac devices. Recent studies demonstrated the diagnostic value of other imaging strategies including cardiac computed tomography (CT), positron emission tomography/CT, radiolabelled leukocyte single-photon emission CT/CT, and cerebral magnetic resonance imaging. Novel perspectives on the management of endocarditis are emerging and offer a hope for decreasing the rate of residual deaths by accelerating the processes of diagnosis, risk stratification, and instauration of antimicrobial therapy. Moreover, the rapid transfer of high-risk patients to specialized mediosurgical centres (IE team), the development of new surgical modalities, and close long-term follow-up are of crucial importance.

Multiphoton laser microscopy and fluorescence lifetime imaging for the evaluation of the skin.

Multiphoton laser microscopy is a new, non-invasive technique providing access to the skin at a cellular and subcellular level, which is based both on autofluorescence and fluorescence lifetime imaging. Whereas the former considers fluorescence intensity emitted by epidermal and dermal fluorophores and by the extra-cellular matrix, fluorescence lifetime imaging (FLIM), is generated by the fluorescence decay rate. This innovative technique can be applied to the study of living skin, cell cultures and ex vivo samples. Although still limited to the clinical research field, the development of multiphoton laser microscopy is thought to become suitable for a practical application in the next few years: in this paper, we performed an accurate review of the studies published so far, considering the possible fields of application of this imaging method and providing high quality images acquired in the Department of Dermatology of the University of Modena.

Clinical Features, Management, and Outcomes of Immune Checkpoint Inhibitor–Related Cardiotoxicity

Immune checkpoint inhibitors (ICIs) represent a major advance in the treatment of cancer. Although clinical trials reported a low incidence of immune-related cardiovascular adverse events,1 the number of published life-threatening cases of cardiotoxicity is increasing.2 In this descriptive observational analysis, we aimed to describe the clinical manifestations, management, and outcomes of patients who developed ICI-related cardiotoxicity. The medical records of patients with a clinical suspicion of ICI-related cardiotoxicity were reviewed from the databases of 2 cardio-oncology units between March 2015 and April 2017. The patients are managed according to similar protocols. Because no specific follow-up had previously been established for patients receiving ICIs during the study period, the oncologists referred patients receiving ICIs only on the basis of their clinical suspicion of cardiovascular events. These patients had a standardized evaluation including clinical consultation, ECG, transthoracic echocardiography, and measurement of brain natriuretic peptide and troponin I serum levels. The management of cardiotoxicity was left to the physician’s discretion. The study was approved by our institutional review board, and informed consent has been obtained from the subjects. To create a pooled analysis, we also searched PubMed for English articles reporting cases of ICI-related cardiotoxicity until April 2017. We selected …

Management and research in cancer treatment-related cardiovascular toxicity: Challenges and perspectives

Cardiovascular toxicity is a potentially serious complication that can result from the use of various cancer therapies and can impact the short- and long-term prognosis of treated patients as well as cancer survivors. In addition to their potential acute cardiovascular adverse events, new treatments can lead to late toxicity even after their completion because patients who survive longer generally have an increased exposure to the cancer therapies combined to standard cardiovascular risk factors. These complications expose the patient to the risk of cardiovascular morbi-mortality, which makes managing cardiovascular toxicity a significant challenge. Cardio-oncology programs offer the opportunity to improve cardiovascular monitoring, safety, and management through a better understanding of the pathogenesis of toxicity and interdisciplinary collaborations. In this review, we address new challenges, perspectives, and research priorities in cancer therapy-related cardiovascular toxicity to identify strategies that could improve the overall prognosis and survival of cancer patients. We also focus our discussion on the contribution of cardio-oncology in each step of the development and use of cancer therapies.

Practices in management of cancer treatment-related cardiovascular toxicity: A cardio-oncology survey

BACKGROUND Cardiovascular toxicity has become a challenging issue during cancer therapy. Nonetheless, there is a lack of consensual guidelines for their management. We aimed to determine the current practices of oncologists regarding cardiovascular toxicity related to anthracyclines, trastuzumab and angiogenic inhibitors and to gather their opinions on the development of cardio-oncology programs. METHODS A cross-sectional declarative study was submitted to French oncologists in the form of an individual, structured questionnaire. RESULTS A total of 303 oncologists responded to the survey. Ninety-nine percent of oncologists prescribed cardiotoxic therapies, including anthracyclines (83%), trastuzumab (51%) and other angiogenic inhibitors (64%). The method adopted for managing cardiovascular toxicity was based on guidelines from expert oncology societies for only 35% of oncologists. None was aware of recommendations from expert cardiology societies. Prescription of pre-, peri- and post-therapy cardiovascular assessment was inconsistent and significantly less frequent for all classes of angiogenic inhibitors than for anthracyclines and trastuzumab (P<0.0001). Relative to pre-therapy assessment, post-therapy assessment was prescribed significantly less often for all cancer therapies (P<0.0001). Attitudes regarding the onset of left ventricular dysfunction were much more inconsistent when angiogenic inhibitors were involved. Additionally, the management of hypertension and QT prolongation was also inconsistent. Finally, 88% of oncologists supported projects of cardio-oncology programs development. CONCLUSIONS Practices of oncologists are disparate in the field of cardiovascular toxicity. This finding underlines the complexity of managing many different situations and the need for distribution of formal guidelines from oncology and cardiology expert societies. The development of personalized cardio-oncology programs seems essential.

Wearable cardioverter defibrillator: Bridge or alternative to implantation?

The implantable cardioverter-defibrillator (ICD) is effective to prevent sudden cardiac death (SCD) in selected patients with heart disease known to be at high risk for ventricular arrhythmia. Nevertheless, this invasive and definitive therapy is not indicated in patients with potentially transient or reversible causes of sudden death, or in patients with temporary contra-indication for ICD placement. The wearable cardioverter defibrillator (WCD) is increasingly used for SCD prevention both in patients awaiting ICD implantation or with an estimated high risk of ventricular arrhythmia though to be transient. We conducted a review of current clinical uses and benefits of the WCD, and described its technical aspects, limitations and perspectives.

Ventricular Arrhythmia Occurrence and Compliance in Patients Treated With the Wearable Cardioverter Defibrillator Following Percutaneous Coronary Intervention

BACKGROUND The wearable cardioverter defibrillator (WCD) is a life-saving therapy in patients with high risk of arrhythmic death. We aimed to evaluate ventricular arrhythmia (VA) occurrence rate and compliance with the WCD during the first 90 days following myocardial revascularisation with percutaneous coronary intervention (PCI) in patients with left ventricular ejection fraction (LVEF) <30%. METHODS From September 2015 to November 2016, clinical characteristics, WCD recordings and compliance data of the aforementioned subset of patients were prospectively collected. RESULTS Twenty-four patients (men=20, 80%) were included in this analysis. Mean age was 56±10 years and mean LVEF at enrolment was 26.6±4.3%. During a mean wearing period of 3.0±1.3 months, two episodes of VA occurred in two patients (8.3%): one successfully treated with WCD shock and one with spontaneous termination. The mean and median daily use of the WCD was 21.5hours and 23.5hours a day, respectively. Eighteen patients (75%) wore the WCD more than 22hours a day. CONCLUSIONS The rate of VA, during the WCD period use after myocardial revascularisation with PCI, was high in our study. Otherwise it underlined that patient compliance is critical during the WCD period use. Remote monitoring and patient education are keys to achieve good compliance.

Prevalence and characteristics of coronary artery disease in heart failure with preserved and mid-range ejection fractions: A systematic angiography approach

BACKGROUND Guidelines recommend careful screening and treatment of coronary artery disease (CAD) in heart failure with preserved or mid-range ejection fraction (HFpEF/HFmEF). AIM We aimed to determine the prevalence and characteristics of CAD using a prospective systematic coronary angiography approach. METHODS A systematic coronary angiography protocol was applied in consecutive patients admitted for HFpEF/HFmEF during a 6-month period in a single centre. History of CAD and results of angiography, including revascularization, were reported. RESULTS Of the 164 patients with HFpEF/HFmEF who were included, an angiography assessment was applied in 108 (66%) (median age: 79 years [interquartile range: 70-85 years]; 54% were women). In our analysis, 64% (95% confidence interval [CI] 55-73%) of patients had a significant coronary stenosis corresponding to a global CAD prevalence of 80% (95% CI 73-88%). The prevalence of CAD was similar for HFpEF and HFmEF. The left main coronary artery presented a significant stenosis in 6.5% of cases and 39% of patients had a two- or three-vessel disease. The rate of significant coronary stenosis was non-significantly higher in patients with a history of CAD. Patients with HFpEF/HFmEF with and without CAD did not differ in clinically meaningful ways, in terms of symptoms or laboratory and echocardiography results. This strategy led to complete revascularization in 36% of patients with significant stenosis and in 23% of all patients with HFpEF/HFmEF. CONCLUSIONS Our study differs from others in that we used a systematic angiography approach. The results suggest a much higher prevalence of CAD in HFpEF/HFmEF than previously reported and should encourage clinicians to aggressively identify this co-morbidity.

Pleiotropic effects of ticagrelor: Myth or reality?

In the PLATO study, ticagrelor, a direct-acting and reversible P2Y12 adenosine diphosphate receptor blocker, slightly but significantly reduced the incidence of cardiovascular and total mortality compared with clopidogrel [1]. The accuracy of the PLATO mortality data has been questioned by some authors [2]. In an adjusted indirect meta-analysis comparing prasugrel with ticagrelor for acute coronary syndromes (ACS), prasugrel and ticagrelor