María del C. Manzano

Acute Coronary Syndrome in Infective Endocarditis

INTRODUCTION AND OBJECTIVES To describe the clinical, microbiologic, echocardiographic characteristics, and disease progression in patients who experience an acute coronary syndrome during an episode of endocarditis. METHODS The study included 586 consecutive patients who were diagnosed of infective endocarditis (481 left-sided) at one of five hospitals between 1995 and 2005. RESULTS Overall, 14 patients (2.9%) had an acute coronary syndrome. Their mean age was 50 (17) years, and 50% had a prosthetic valve. For 11 episodes of endocarditis, laboratory cultures tested positive, with Staphylococcus aureus being the most frequently isolated microorganism. Vegetations were detected by transesophageal echography in 12 cases. The infection was located in the aortic valve in 12 cases. In the 14 patients, periannular complications were found more frequently (11 [78.6%] vs 172 [36.8%]; P=.03), and their size was greater than in other patients. Thirteen had moderate-to-severe valvular regurgitation. In most patients, acute coronary syndrome was an early complication of endocarditis. Myocardial ischemia was due to an embolism in three cases and to coronary artery compression in eight. During follow-up, patients with acute coronary syndrome had higher incidences of heart failure (6 [42.85%] vs 77 [16.48%]; P=.021), cardiogenic shock (5 [35.7%] vs 71 [15.2%]; P=.038), complete atrioventricular block (4 [28.57%] vs 43 [9.2%]; P=.039), and mortality (9 [64.29%] vs 151 [32.33%]; P=.019). CONCLUSIONS Acute coronary syndrome is usually an early complication of infective endocarditis. It is associated with virulent microorganisms, aortic valve infection, severe valvular regurgitation, extensive periannular complications, and increased mortality. The most frequent cause of myocardial ischemia was coronary artery compression secondary to periannular complications.

Chronic mitral regurgitation: a pilot study to assess preoperative left ventricular contractile function using speckle-tracking echocardiography.

BACKGROUND The development of postoperative left ventricular (LV) dysfunction is a frequent complication in patients with chronic severe mitral regurgitation (MR) and implies a poor prognosis. The aim of this study was to evaluate the predictive value of preoperative regional LV contractile function assessment using two-dimensional echocardiography-based speckle-tracking analysis in patients with chronic severe MR. METHODS Thirty-eight consecutive patients with chronic severe MR scheduled for mitral valve replacement were prospectively enrolled. Preoperative two-dimensional echocardiography-based speckle-tracking analysis at the level of the interventricular septum (IVS) was carried out, and strain and strain rate values were obtained. LV dP/dt and Doppler tissue imaging-derived strain and strain rate measurements were also obtained. LV volumes and LV ejection fraction (LVEF) were defined using three-dimensional echocardiography. RESULTS Preoperative speckle tracking-derived longitudinal strain and strain rate values at the level of the IVS strongly predicted a postoperative LVEF decrease of >10%. Their predictive values were greater than those obtained for preoperative LV volumes and LVEF, LV dP/dt, and Doppler tissue imaging-derived strain and strain rate. The best discriminant parameter to detect a postoperative LVEF reduction of >10% with speckle tracking was a longitudinal strain rate at the level of the mid IVS < -0.80 s(-1) (area under the receiver operating characteristic curve, 0.88; sensitivity, 60%; specificity, 96.5%; positive predictive value, 90%; negative predictive value, 82.35%). CONCLUSIONS IVS longitudinal speckle tracking-derived strain rate allows the accurate detection of early abnormalities in LV contractile function. It is a powerful predictor of early postoperative LVEF decreases in patients with chronic severe MR. Furthermore, speckle-tracking technology is more accurate than other methods. This new tool might assist clinicians in the optimal timing of surgery in patients with chronic severe MR.

Síndrome coronario agudo en la endocarditis infecciosa

Introduccion y objetivos Describir las caracteristicas epidemiologicas, clinicas, microbiologicas, ecocardiograficas y evolutivas de los pacientes con un sindrome coronario agudo en el seno de una endocarditis. Metodos Hemos analizado 586 episodios de endocarditis (481 izquierdos) diagnosticados de forma consecutiva en 5 hospitales desde 1995 hasta 2005. Resultados Hubo 14 pacientes (2,9%) con un sindrome coronario agudo, con una edad media de 50 ± 17 anos. El 50% tenian una protesis valvular. Los cultivos fueron positivos en 11 episodios y el germen aislado con mas frecuencia fue Staphylococcus aureus. La ecocardiografia transesofagica detecto vegetaciones en 12 casos. La localizacion de la infeccion fue aortica en 12 casos. Se documentaron con mas frecuencia complicaciones perivalvulares (n = 11 [78,6%] frente a n = 172 [36,8%]; p = 0,03) y su tamano fue mayor que el de los otros pacientes de la serie. Trece pacientes tuvieron insuficiencia valvular de moderada a severa. El sindrome coronario agudo se manifesto precozmente en la mayoria de los pacientes. El mecanismo de la isquemia fue embolico en 3 casos y por compresion coronaria en 8. Durante la evolucion, los pacientes con sindrome coronario agudo tuvieron una mayor incidencia de insuficiencia cardiaca (n = 6 [42,85%] frente a n = 77 [16,48%]; p = 0,021), shock cardiogenico (n = 5 [35,7%] frente a n = 71 [15,2%]; p = 0,038) y bloqueo auriculoventricular (n = 4 [28,57%] frente a 43 [9,2%]; p = 0,039). La mortalidad fue tambien superior en estos pacientes (n = 9 [64,29%] frente a n = 151 [32,33%]; p = 0,019). Conclusiones El sindrome coronario agudo es una complicacion precoz de la endocarditis. Se asocia mas a microorganismos virulentos, infeccion valvular aortica, insuficiencia valvular severa, complicaciones perianulares de gran tamano y elevada mortalidad. El mecanismo mas frecuente fue la compresion coronaria secundaria a complicaciones perianulares.

Rationale, design, and methods for the early surgery in infective endocarditis study (ENDOVAL 1): A multicenter, prospective, randomized trial comparing the state-of-the-art therapeutic strategy versus early surgery strategy in infective endocarditis

BACKGROUND The prognosis of infective endocarditis is poor and has remained steady over the last 4 decades. Several nonrandomized studies suggest that early surgery could improve prognosis. METHODS ENDOVAL 1 is a multicenter, prospective, randomized study designed to compare the state-of-the-art therapeutic strategy (advised by the international societies in their guidelines) with the early-surgery strategy in high-risk patients with infective endocarditis. Patients with infective endocarditis without indication for surgery will be included if they meet at least one of the following: (1) early-onset prosthetic endocarditis; (2) Staphylococcus aureus endocarditis; (3) periannular complications; (4) new-onset conduction abnormalities; (5) new-onset severe valvular dysfunction. A total of 216 patients will be randomized to either of the 2 strategies. Stratification will be done within 3 days of admission. In the early surgery arm, the surgical procedure will be performed within 48 hours of randomization. The only event to be considered will be death within 30 days. The study will be extended to 1 year. In the follow-up substudy, death and a new episode of endocarditis will be regarded as events. CONCLUSION ENDOVAL 1, the first randomized study on endocarditis, will provide crucial information regarding the putative benefit of early surgery over the state-of-the-art therapeutic approach in high-risk patients with infective endocarditis.

Isolated Right-Sided Valvular Endocarditis in Non-Intravenous Drug Users

INTRODUCTION AND OBJECTIVES Characteristics of isolated right-sided endocarditis in patients without a pacemaker and who are not intravenous drug users (IVDU) are poorly understood. The aim of this study was to investigate the current frequency of this entity and describe its clinical, microbiological, echocardiographic and prognostic profile. METHODS We have prospectively analyzed 17 consecutive cases of isolated right-sided endocarditis in non-IVDU who did not have a pacemaker, out of a total of 583 consecutive episodes of endocarditis (2.9%). RESULTS Mean age was 38+/-15 years; 11 of the 17 patients were men. Almost half of the patients had at least one predisposing disease. An intravascular catheter was the most frequent port of entry (35%). The most common signs and symptoms on admission were fever, dyspnea, septic pulmonary embolisms, pleural effusion and right-sided heart failure. The most frequent microorganism was Staphylococcus aureus (41%). In most cases (82%) the infection was located in the tricuspid valve. Recurrent pulmonary embolisms were the most frequent complication and the main cause for surgery, which was needed in 5 patients (29%). Two patients died during hospitalization (12%), both from septic shock. During follow-up one patient died of unknown causes 1 month after discharge, and other relapsed 3 months after discharge. CONCLUSIONS Isolated right-sided endocarditis should be included in the differential diagnosis of patients with febrile syndrome, respiratory symptoms and predisposing disease, even when they do not have a pacemaker and are not IVDU. The presence of intravascular catheters and Staphylococcus bacteriemia should heighten suspicion of endocarditis.

Endocarditis derecha aislada en pacientes no adictos a drogas por vía parenteral

Introduccion y objetivos La endocarditis derecha aislada es una entidad poco conocida cuando afecta a pacientes no portadores de marcapasos y no adictos a drogas por via parenteral (ADVP). Nuestro objetivo es estudiar la frecuencia actual de esta entidad y describir su perfil clinico, microbiologico, ecocardiografico y pronostico. Metodos Hemos analizado 17 casos de endocarditis derecha aislada en pacientes no ADVP y no portadores de marcapasos, de un total de 583 episodios consecutivamente diagnosticados de endocarditis infecciosa (3%). Resultados La media de edad fue 38 ± 15 anos y 11 pacientes eran varones. El 47% de los pacientes presentaban alguna enfermedad predisponente. El cateter intravascular fue la puerta de entrada mas frecuente (35%). Los sintomas y signos mas comunes al ingreso fueron fiebre, disnea, embolia pulmonar septica, derrame pleural e insuficiencia cardiaca derecha. El microorganismo mas frecuente fue Staphylococcus aureus (41%). La mayoria de los casos asentaron en la valvula tricuspide (82%). La embolia pulmonar recurrente fue la complicacion mas frecuente y la principal causa de cirugia, que fue precisa en 5 (29%) casos. Fallecieron 2 (12%) pacientes, ambos por shock septico. En el seguimiento, 1 paciente fallecio al mes del alta por causa desconocida y 1 presento una recaida al tercer mes. Conclusiones La endocarditis derecha aislada debe incluirse en el diagnostico diferencial de pacientes con sindrome febril, sintomas respiratorios y alguna enfermedad predisponente, aunque no sean portadores de marcapasos o ADVP. La presencia de cateteres intravasculares y la bacteriemia por estafilococos refuerzan la sospecha de endocarditis en estos pacientes.

Distortion of the terminal portion of the QRS is associated with poor collateral flow before and poor myocardial perfusion after percutaneous revascularization for myocardial infarction.

AimsThe distortion of the terminal portion of the QRS has been related to adverse outcome in patients with ST-segment elevation myocardial infarction. MethodsWe studied the relationship of this electrocardiographic pattern with the angiographic findings in patients treated with percutaneous revascularization for ST-segment elevation myocardial infarction. We included 349 patients, 318 treated with primary angioplasty and 31 with rescue angioplasty after failed thrombolysis. ResultsEighty-five patients were found with distortion of the terminal portion of the QRS complex (group 1) and 264 without it (group 2). Collateral flow was absent in 30 patients (35%) from group 1, versus 52 patients (20%) from group 2 [odds ratio (OR) 1.806, 1.097–2.974, P 0.019]. No-reflow occurred in 12 (14%) patients in group 1 versus 17 (6.4%) in group 2 (OR 2.388, 1.091–5.230, P 0.016). Myocardial perfusion was graded 2–3 in 28 patients (58%) of group 1 versus 98 (76%) in group 2 (OR 0.443, 0.220–0.893, P 0.021). ConclusionPatients with ST-segment elevation myocardial infraction showing distortion of the terminal portion of the QRS have worse collateral flow, and present more often no-reflow or poor myocardial perfusion after percutaneous revascularization. These data contribute to explain the worse clinical outcome of these patients.

Estudio de la deformación miocárdica: predictor de disfunción ventricular a medio plazo tras cirugía en pacientes con insuficiencia mitral crónica

Introduccion y objetivos. El desarrollo de disfuncion ventricular izquierda tras la sustitucion valvular mitral es un problema frecuente en pacientes con insuficiencia mitral grave cronica. El analisis de la deformacion miocardica permite estimar con precision la contractilidad miocardica. Nuestro objetivo fue comparar el valor predictivo de strain (S) y strain rate (SR) preoperatorios obtenidos por speckle-tracking y Doppler tisular (DTI) para predecir la disminucion de la fraccion de eyeccion del ventriculo izquierdo (FEVI) a medio plazo tras la cirugia. Metodos. Treinta y ocho pacientes consecutivos con insuficiencia mitral grave cronica programados para sustitucion valvular mitral fueron incluidos prospectivamente. Se analizo el S y el SR longitudinal del septo interventricular en el periodo preoperatorio mediante speckle-tracking y DTI. La FEVI preoperatoria y postoperatoria se obtuvo por ecocardiografia tridimensional. Los estudios ecocardiograficos se realizaron dentro de las 48 h previas a la cirugia y 6 meses despues de la cirugia. Resultados. La media de edad de los pacientes era 59,9 ± 11,3 anos; 10 pacientes (29,4%) eran varones. Tanto el speckle-tracking como el DTI resultaron predictores de disminucion de la FEVI > 10% a 6 meses. Sin embargo, el valor predictivo del speckle-tracking fue superior al del DTI. El S longitudinal del septo interventricular basal mediante speckle-tracking fue el parametro con mayor poder predictivo, con un area bajo la curva de 0,85 y un punto de corte optimo de -0,11. Conclusiones. El speckle-tracking permite predecir la disminucion de la FEVI a medio plazo tras la sustitucion valvular mitral. Ademas, el speckle-tracking es mas preciso que el DTI para este fin.

Calcified right ventricular thrombus and antiphospholipid syndrome

Antiphospholipid syndrome has been associated with venous and arterial thrombotic events but intracardiac thrombosis is rare. We describe a case about a 30-year-old woman, admitted with a 6-month history of arthralgia, fatigue, and intermittent fever. Subsequent investigation revealed the presence of a large and calcified mass in the right ventricular outflow tract attached to the subvalvular tricuspid apparatus. Cardiac surgery was performed and histological examination demonstrated it to be composed entirely of calcified thrombus. Screening laboratory evaluation for hypercoagulable states confirmed the diagnosis of antiphospholipid syndrome.

In-Hospital Prognostic Value of Glomerular Filtration Rate in Patients With Acute Coronary Syndrome and a Normal Creatinine Level

INTRODUCTION AND OBJECTIVES Kidney failure is more prevalent in patients with ischemic heart disease than in the general population. A high serum creatinine level is known to be a predictor of an adverse outcome in acute coronary syndrome. The aim of this study was to investigate the clinical significance of the glomerular filtration rate in patients with acute coronary syndrome and a normal baseline creatinine level. METHODS The study included 583 consecutive patients admitted to a coronary care unit with acute coronary syndrome (with or without ST-segment elevation) whose baseline serum creatinine level was less than 1.3 mg/dL. The creatinine clearance rate at admission was calculated using the Cockcroft-Gault equation, and the presence of cardiovascular risk factors, coronary anatomy (from angiography), type of revascularization, maximum cardiac enzyme levels, left ventricular ejection fraction and, ultimately, in-hospital mortality were recorded. RESULTS Around 50.8% of patients presented with ST-segment elevation acute coronary syndrome. The median serum creatinine level on admission was 0.98 mg/dL (0.9-1.1 mg/dL) and the median creatinine clearance rate was 81.29 mL/min (61.2-98.4 mL/min). The in-hospital mortality rate was 2.7%. Glomerular filtration rate, previous coronary disease, Killip class on admission, and the need for intraaortic balloon counterpulsation were found to be independent predictors of mortality. CONCLUSIONS In patients with acute coronary syndrome and a normal creatinine level on admission, estimation of the glomerular filtration rate provided important information on short-term prognosis. This parameter should be included in the risk assessment of patients with normal serum creatinine levels.