Manuel Azqueta

Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles

Objective: To evaluate the incidence and the clinical and echocardiographic features of infective endocarditis (IE) caused by Staphylococcus lugdunensis and to identify the prognostic factors of surgery and mortality in this disease. Design: Prospective cohort study. Setting: Study at two centres (a tertiary care centre and a community hospital). Patients: 10 patients with IE caused by S lugdunensis in 912 consecutive patients with IE between 1990 and 2003. Methods: Prospective study of consecutive patients carried out by the multidisciplinary team for diagnosis and treatment of IE from the study institutions. English, French, and Spanish literature was searched by computer under the terms “endocarditis” and “Staphylococcus lugdunensis” published between 1989 and December 2003. Main outcome measures: Patient characteristics, echocardiographic findings, required surgery, and prognostic factors of mortality in left sided cases of IE. Results: 10 cases of IE caused by S lugdunensis were identified at our institutions, representing 0.8% (four of 467), 1.5% (two of 135), and 7.8% (four of 51) of cases of native valve, prosthetic valve, and pacemaker lead endocarditis in the non-drug misusers. Native valve IE was present in four patients (two aortic, one mitral, and one pulmonary), prosthetic valve aortic IE in two patients, and pacemaker lead IE in the other four patients. All patients with left sided IE had serious complications (heart failure, periannular abscess formation, or shock) requiring surgery in 60% (three of five patients) of cases with an overall mortality rate of 80% (four of five patients). All patients with pacemaker IE underwent combined medical treatment and surgery, and mortality was 25% (one patient). In total 59 cases of IE caused by S lugdunensis were identified in a review of the literature. The combined analysis of these 69 cases showed that native valve IE (53 patients, 77%) is characterised by mitral valve involvement and frequent complications such as heart failure, abscess formation, and embolism. Surgery was needed in 51% of cases and mortality was 42%. Prosthetic valve endocarditis (nine of 60, 13%) predominated in the aortic position and was associated with abscess formation, required surgery, and high mortality (78%). Pacemaker lead IE (seven of 69, 10%) is associated with a better prognosis when antibiotic treatment is combined with surgery. Conclusions:S lugdunensis IE is an uncommon cause of IE, involving mainly native left sided valves, and it is characterised by an aggressive clinical course. Mortality in left sided native valve IE is high but the prognosis has improved in recent years. Surgery has improved survival in left sided IE and, therefore, early surgery should always be considered. Prosthetic valve S lugdunensis IE carries an ominous prognosis.

Streptococcus agalactiae Infective Endocarditis: Analysis of 30 Cases and Review of the Literature, 1962–1998

We describe 30 cases (1.7%) of community-acquired penicillin-susceptible Streptococcus agalactiae endocarditis among 1771 episodes of endocarditis diagnosed in 4 Spanish hospitals from 1975 through 1998. Endocarditis affected a native valve (most often the mitral valve) in 25 cases (83%). Surgical valve replacement was performed for 12 patients (40%). Fourteen patients (47%) died. Mortality rates for patients with native and prosthetic valve endocarditis were 36% and 100%, respectively (P=.01). The mortality rate for native valve endocarditis decreased during the last 6 years of the study (from 61% in 1975-1992 to 8% in 1993-1998; P<.05). Additionally, 115 cases in the literature from 1962-1998 were reviewed. During 1980-1998, the percentage of patients who underwent cardiac surgery increased from 24% (in the previous period, 1962-1979) to 43% (P=.05) and the mortality rate decreased from 45% to 34% (P=NS). S. agalactiae is an uncommon cause of endocarditis with a high mortality rate, although the prognosis of native valve endocarditis has improved in recent years, probably because of an increased use of cardiac surgery.

Fate of left atrial function as determined by real-time three-dimensional echocardiography study after radiofrequency catheter ablation for the treatment of atrial fibrillation.

Radiofrequency catheter ablation has been demonstrated to be effective in the treatment of patients with atrial fibrillation. However, its impact on left atrial (LA) function has not been widely studied. The purpose of the present study was to evaluate the impact of radiofrequency catheter ablation on LA function in patients with atrial fibrillation. Thirty-eight patients with symptomatic drug-refractory atrial fibrillation were treated with circumferential pulmonary vein ablation (CPVA). LA volumes and function were assessed with real-time 3-dimensional echocardiography before and 6 months after the procedure. The effectiveness of CPVA was evaluated at 6-month follow-up. Recurrence of the arrhythmia was defined as any documented (clinically or on 24-hour Holter electrocardiography) atrial tachyarrhythmia lasting>30 seconds after the first 12 weeks after the procedure. CPVA induced a reduction of maximum LA volume (from 55+/-15 to 48+/-16 ml, p<0.001), without impairment in LA function, measured as the active emptying percentage of total volume (32+/-29% vs 39+/-33%, p=NS). At follow-up, 21 patients (61.8%) had no recurrences. Maximum LA volumes were significantly larger in patients who presented with recurrences compared with those who did not (64+/-18 vs 50+/-11 ml, p=0.01). In conclusion, CPVA induces a reduction in LA volume without a deleterious impact on function, and, of importance, real-time 3-dimensional echocardiography is a useful noninvasive imaging tool to follow up LA remodeling and function in these patients.

Usefulness of transoesophageal echocardiography before circumferential pulmonary vein ablation in patients with atrial fibrillation: is it really mandatory?

AIMS Transoesophageal echocardiography (TEE) is recommended prior to circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) to identify left atrial (LA) or left atrial appendage (LAA) wall thrombi. It is not clear whether all patients undergoing CPVA should receive pre-procedural TEE. We wanted to assess the incidence of LA thrombus in these patients and to identify factors associated with its presence. METHODS AND RESULTS Consecutive patients referred for CPVA from 2004 to 2009 underwent TEE within 48 h prior to the procedure. Of 408 patients included in the study, 6 patients (1.47%) had LA thrombi, persistent AF, and LA dilation. Compared with patients without thrombus, these six patients had larger LA diameter (P = 0.0001) and more frequently were women (P = 0.002), had persistent AF (P = 0.04), and had underlying structural cardiac disease (P = 0.014). The likelihood of presenting LA thrombus increased with the number of these four risk factors present (P < 0.001). None of the patients with paroxysmal AF and without LA dilation had LA thrombus. A cut-off value of 48.5 mm LA diameter yielded 83% sensitivity, 92% specificity, and a 10.1 likelihood ratio to predict LA thrombus appearance. CONCLUSION The incidence of LA thrombus prior to CPVA is low. Persistent AF, female sex, structural cardiopathy, and LA dilation were associated with the presence of LA thrombus. Our data suggest that the use of TEE prior to CPVA to detect LA thrombi might not be needed in patients with paroxysmal AF and no LA dilation or structural cardiopathy.

Feasibility of early discharge after acute Q wave myocardial infarction in patients not receiving thrombolytic treatment

OBJECTIVES The purpose of this study was to analyze the feasibility of early discharge (4 days) after acute myocardial infarction in patients not receiving thrombolytic therapy by first identifying predictors of short-term prognosis and then testing the derived risk profile in an independent cohort of patients. BACKGROUND Previous studies have shown that early discharge after acute myocardial infarction is possible. However, physicians are reluctant to shorten the standard 7- to 10-day hospital stay, presumably because of difficulty in selecting low risk patients. METHODS From January 1985 to November 1986, 358 patients with acute myocardial infarction who did not receive thrombolytic therapy were screened. Those with a Q-wave infarction showing no complications on day 4 were considered candidates for early discharge and were transferred to the ward for a mean of 12 days. During this period, we looked for any event (cardiac or noncardiac) that would have prompted readmission if the patient had been previously discharged. Univariate and multiple regression analysis were performed to identify predictors of these events among 25 baseline variables. The derived risk profile was tested in an independent validation cohort. RESULTS One hundred five (29.3%) of the 358 patients were free of symptoms on day 4, and 29 (27.6%) had at least one cardiac event, including four deaths and one reinfarction. Multivariate analysis selected diabetes, ejection fraction < 40% and age as independent predictors of events. Using the risk profile, 18 (13.2%) of the 136 validation cohort patients were categorized as low risk, and only 1 of them had a major event (progressive angina). Sensitivity for the risk profile was high (91%), but specificity was low (34%). CONCLUSIONS The use of simple clinical variables may allow the safe reduction of hospital stay after infarction in selected patients. However because the proportion of candidates for early discharge is small (12.6%), it seems unlikely that the current policies on length of hospital stay will change in the near future.

Assessment of Left Ventricular Dyssynchrony by Real-Time Three-Dimensional Echocardiography

INTRODUCTION AND OBJECTIVES A number of different imaging methods have been proposed as possible tools for assessing left ventricular (LV) mechanical dyssynchrony. The aim of this study was to evaluate the usefulness of real-time three-dimensional echocardiography (RT3DE) for studying LV mechanical dyssynchrony. METHODS In total, 60 individuals underwent RT3DE, including 10 healthy volunteers, 23 patients with acute ST-segment elevation myocardial infarction and 27 patients with dilated cardiomyopathy. The LV volume was recorded throughout the full cardiac cycle using RT3DE, after which LV mechanical dyssynchrony was determined. The extent of LV mechanical dyssynchrony was characterized using the systolic dyssynchrony index (SDI), which was calculated from the variation in the time required to reach the minimum regional systolic volume in the 16 LV segments analyzed. RESULTS The SDI was significantly higher in patients with dilated cardiomyopathy, at 14.3%+/-7.5% compared with 1.5%+/-0.7% in healthy volunteers and 8.1%+/-7.1% in acute myocardial infarction patients (ANOVA, P< .001). Basal and mid ventricular segments showed the greatest delays. All patients with dilated cardiomyopathy received cardiac resynchronization therapy. In this patient subgroup, the SDI exhibited an immediate significant decrease (to 9.7%+/-6.8%; P< .05) and a progressive decrease during 6 months of follow-up (to 4.9%+/-3.1%; P< .05). CONCLUSIONS The new imaging technique of RT3DE can be used to assess LV mechanical dyssynchrony and is able to identify the LV segments with the greatest time delays.

Quantification of left ventricular asynchrony throughout the whole cardiac cycle with a computed algorithm: application for optimizing resynchronization therapy.

Introduction: Measurement of left ventricular (LV) asynchrony is usually determined on single time points from spectral tissue Doppler imaging (TDI) scans that are frequently difficult to identify or not representative of the whole cardiac cycle. Our aim was to validate a new asynchrony index that evaluates the motion of the LV walls throughout the whole cardiac cycle.

Role of Echocardiogram in Decision Making for Surgery in Endocarditis

Infective endocarditis is a serious disease that carries significant morbidity and mortality. Adequate treatment is based on a high degree of clinical suspicion, accurate microbiologic diagnosis, and high-quality imaging. Echocardiography has been shown to be a fundamental tool for diagnosis and management. Currently accepted Duke criteria include blood cultures and echocardiography. Transthoracic and transesophageal echocardiography play a critical role in the decision-making process, especially when surgical treatment is contemplated. Because infective endocarditis is considered a medical and surgical disease, and considering that the current rate of surgery is about 50%, echocardiography has definite value in preoperative diagnosis and surgical planning, intraoperative confirmation of lesions and quality of repair or replacement before and after cardiopulmonary bypass, and postoperative assessment.

Trombosis intracardíaca y síndrome antifosfolípido primario. Un caso familiar

El sindrome antifosfolipido es una entidad clinica poco frecuente que se manifiesta por fenomenos tromboticos de repeticion en pacientes jovenes sin factores de riesgo cardiovascular. Sus formas de presentacion son multiples, pero las mas frecuentes son las perdidas fetales de repeticion y el accidente cerebrovascular. La afeccion cardiaca es menos frecuente. Describimos un caso familiar que se ha presentado con trombosis intracardiaca y embolia cerebral secundaria.