Pablo Elpidio García-Granja

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.

Polymicrobial Infective Endocarditis: Clinical Features and Prognosis

AbstractTo describe the profile of left-sided polymicrobial endocarditis (PE) and to compare it with monomicrobial endocarditis (ME).Among 1011 episodes of left-sided endocarditis consecutively diagnosed in 3 tertiary centers, between January 1, 1996 and December 31, 2014, 60 were polymicrobial (5.9%), 821 monomicrobial (81.7%), and in 123 no microorganism was detected (12.2%). Seven patients (0.7%) were excluded from the analysis because contamination of biologic tissue could not be discarded. The authors described the clinical, microbiologic, echocardiographic, and outcome of patients with PE and compared it with ME.Mean age was 64 years SD 16 years, 67% were men and 30% nosocomial. Diabetes mellitus (35%) were the most frequent comorbidities, fever (67%) and heart failure (43%) the most common symptoms at admission. Prosthetic valves (50%) were the most frequent infection location and coagulase-negative Staphylococci (48%) and enterococci (37%) the leading etiologies. The most repeated combination was coagulase-negative Staphylococci with enterococci (n = 9). Polymicrobial endocarditis appeared more frequently in patients with underlying disease (70% versus 56%, P = 0.036), mostly diabetics (35% versus 24%, P = 0.044) with previous cardiac surgery (15% versus 8% P = 0.049) and prosthetic valves (50% versus 37%, P = 0.038). Coagulase-negative Staphylococci, enterococci, Gram-negative bacilli, anaerobes, and fungi were more frequent in PE. No differences on age, sex, symptoms, need of surgery, and in-hospital mortality were detected.Polymicrobial endocarditis represents 5.9% of episodes of left-sided endocarditis in our series. Despite relevant demographic and microbiologic differences between PE and ME, short-term outcome is similar.

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.

Evolution of Prognosis in Left-Sided Infective Endocarditis: A Propensity Score Analysis of 2 Decades.

Left-sided infective endocarditis (LSIE) bears a high in-hospital mortality rate that has remained unchanged over the past 2 decades [(1)][1]. Our objectives were to investigate whether the clinical profile of patients with LSIE has worsened in this time period and to test the hypothesis that this

Worsening Conduction Delay in Hypertrophic Cardiomyopathy: What Drug Is Responsible?

We present the case of a 64-year-old male who presented to the emergency room because of recent onset palpitations. He was diagnosed with a first episode of atrial fibrillation and was managed at the emergency room by direct current cardioversion. The patient’s past medical record was unremarkable, and no relevant findings were discovered during the physical examination or laboratory tests. The baseline ECG is shown in Figure 1. On discharge the patient was referred for outpatient cardiology evaluation and was eventually seen 2 months later. The ECG at the outpatient clinic is shown in Figure 2. Figure 1. Baseline ECG. Figure 2. ECG at the cardiology outpatient clinic. Which drug was most likely prescribed to the patient to account for the differences between the first and second ECGs? Please turn the page to read the diagnosis. The ECG shows an …

Surgery changes prognosis in infective endocarditis: The importance of post-surgical clinical evolution

BACKGROUND Left-sided infective endocarditis (LSIE) bears a grim prognosis and surgery is needed in more than half of the patients to improve survival. Our hypothesis has been that clinical complications developing after surgery impact prognosis. METHODS Among 1075 consecutive episodes of LSIE, 654 (60.7%) underwent cardiac surgery. Of them, 41 patients (6.3%) died the same day of surgery, 112 (17.2%) died after the first day of surgery during hospital stay and 500 (76.5%) were successfully discharged. We compared the last two groups and performed a multivariable analysis of in-hospital mortality. RESULTS Age (OR 1.02, 95% CI 1.01-1.04), periannular complications (OR 1.9, 95% CI 1.2-3.2) renal failure after surgery (OR 2.4, 95% CI 1.3-4.4) but not before surgery, and septic shock after surgery (OR 9.6, 95% CI 5.4-17.1) but not before surgery are predictive of in-hospital death among LSIE patients who underwent cardiac surgery. CONCLUSION A thorough clinical assessment with prognostic purposes in infective endocarditis after surgery is mandatory. In-hospital mortality of patients with infective endocarditis who undergo surgery depends mainly on the clinical evolution after surgery.

Infective Endocarditis Due to Leuconostoc Species

1. Fulcher J, O’Connell R, Voysey M, et al. Efficacy and safety of LDL-lowering therapy among men and women: Meta-analysis of individual data from 174 000 participants in 27 randomised trials. Lancet. 2015;385:1397–1405. 2. Cannon CP, Blazing MA, Giugliano RP, et al. Protocol Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. N Engl J Med. 2015;372:2387–2397372. 3. Nicholls SJ, Puri R, Anderson T, et al. Effect of Evolocumab on Progression of Coronary Disease in Statin-Treated PatientsThe GLAGOV Randomized Clinical Trial. JAMA. 2016;316:2373–2384. 4. Godzien J, Ciborowski M, Armitage EG, et al. A single in-vial dual extraction strategy for the simultaneous lipidomics and proteomics analysis of HDL and LDL fractions. J Proteome Res. 2016;15:1762–1775. 5. Walley KR. Role of lipoproteins and proprotein convertase subtilisin/kexin type 9 in endotoxin clearance in sepsis. Curr Opin Crit Care. 2016;22:464–469. 6. Sánchez-Hernández RM, Civeira F, Stef M, et al. Homozygous Familial Hypercholesterolemia in Spain: Prevalence and Phenotype-Genotype Relationship. Circ Cardiovasc Genet. 2016;9:504–510.

Mid-term beta-blocker treatment after low risk acute coronary syndrome

Beta-blockers in the early phase of myocardial infarction (MI) have been proven useful in reducing arrhythmias and infarct size; however, there is no clear evidence of long-term clinical benefit in patients with preserved left ventricular function (LVF). In this regard, there are no randomized clinical trials on beta-blocker therapy after acute coronary syndrome (ACS) without reduced LVF and heart failure in the modern era, and the only information comes from studies undertaken in the pre-reperfusion era and from observational studies with heterogeneous patients. Some of these studies do not separate patients according to the type of ACS; others use retrospective data, which bears inherent important limitations; and some others use specific statistical tools to overcome its retrospective nature. Furthermore, several ‘big data’ studies have been recently published, with the strength of the big numbers but the drawback of the quality of the data analysed. We hypothesize that therapy with beta-blockers has no impact on medium-term outcome of patients with low risk ACS and preserved LVF, as there are no known pathophysiological mechanisms which support it. To test it, we designed a prospective registry of low risk non-ST elevation ACS patients that included patients with complete percutaneous revascularization in the absence of heart failure and with preserved LVF between July 2014 and July 2017 in two tertiary hospitals from the same city. According to local treatment protocols, patients from hospital A were discharged on beta-blockers, and patients from hospital B off them. However, five patients from hospital A were discharged without beta-blockers and nine patients from hospital B with them, following the personal decision of their responsible cardiologist. Overall, our two final groups for comparison were made up of 103 patients discharged on beta-blockers and 122 patients off betablockers (Figure 1). The information was homogenously collected for each patient, the proportion of missing data was <5% in all analysed variables and the protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the local ethical committees. We performed a comparative analysis of baseline features of patients based on beta-blocker treatment at discharge to ensure the comparability of the two groups (Table 1). There were some differences between groups: patients on beta-blockers had more diabetes mellitus (34% vs. 15%, p1⁄4 0.002), more frequent involvement of circumflex coronary artery (46% vs. 30%, p1⁄4 0.013) and also had slightly higher levels of creatinine (0.94 0.22 vs. 0.86 0.2mg/dl, p1⁄4 0.006), lower haemoglobin (13.7 1.5 vs. 14.6 1.8 g/dl, p< 0.001), higher left ventricular ejection fraction (65 6 vs. 62 5%, p1⁄4 0.001) and, as expected, lower heart rate at discharge (60 10 vs. 66 10 beats/min, p< 0.001). Patients were monitored every six months during a mean follow up of 15.9 6.9 months, and only two patients were lost (0.9%). There were no differences in major adverse cardiovascular events (MACEs) (death, MI, heart failure, stroke or need for revascularization) among groups, neither in any of the events taken individually or in new onset of atrial fibrillation. Beta-blockers were withdrawn in 10 patients, mostly related to adverse events. Beta-blockers were started after discharge in 25 patients; however, in 13 of them there was no evident reason for this to be done. To assess the possible influence of these crossovers, we performed

Impact of Valve Culture in the Prognosis of Active Left-sided Infective Endocarditis

BACKGROUND The culture of removed cardiac tissues during cardiac surgery of left-sided infective endocarditis (LSIE) helps to guide antibiotic treatment. Nevertheless, the prognostic information of a positive valve culture has never been explored. METHODS Among 1078 cases of LSIE consecutively diagnosed in 3 tertiary centers, we selected patients with positive blood cultures who underwent surgery during the active period of infection and in whom surgical biological tissues were cultured (n = 429). According to microbiological results, we constructed 2 groups: negative valve culture (n=218) and concordant positive valve culture (CPVC) (n=118). We compared their main features and performed a multivariable analysis of in-hospital mortality. RESULTS Patients with CPVC presented more nosocomial origin (32% vs 20%, P = .014), more septic shock (21% vs 11%, P = .007), and higher Risk-E score (29% vs 21%, P = .023). Their in-hospital mortality was higher (35% vs 19%, P = .001), despite an earlier surgery (3 vs 11 days from antibiotic initiation, P < .001). Staphylococcus species (61% vs 42%, P = .001) and Enterococcus species (20% vs 9%, P = .002) were more frequent in the CPVC group, whereas Streptococcus species were less frequent (14% vs 42%, P < .001). Independent predictors for in-hospital mortality were renal failure (odds ratio [OR], 2.6 [95% confidence interval {CI}, 1.5-4.4]), prosthesis (OR, 1.9 [95% CI, 1.1-3.5]), Staphylococcus aureus (OR, 1.8 [95% CI, 1.02-3.3]), and CPVC (OR, 2.3 [95% CI, 1.4-3.9]). CONCLUSIONS Valve culture in patients with active LSIE is an independent predictor of in-hospital mortality.

Response by García-Granja et al to Letter Regarding Article, “Worsening Conduction Delay in Hypertrophic Cardiomyopathy: What Drug Is Responsible?”

We have read with interest the letter by Jin-shan and Xue-bin regarding our case,1 and we aim to answer their questions. First, they suggest that ECG changes indicating structural abnormality and preexisting conduction delay would preclude propafenone administration. We fully agree on this point, and it is one of the key messages of the clinical case. IC antiarrhythmic drugs are the most powerful sodium channel blockers, and they produce the strongest myocardial conduction delay and therefore prolongation in conduction intervals.2 However, the prolongation of conduction intervals is dose-dependent, and it can appear even in the presence of a …