Ramón Cartañá

Efficacy and Safety of Fosfomycin Plus Imipenem as Rescue Therapy for Complicated Bacteremia and Endocarditis Due to Methicillin-Resistant Staphylococcus aureus: A Multicenter Clinical Trial

BACKGROUND There is an urgent need for alternative rescue therapies in invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA). We assessed the clinical efficacy and safety of the combination of fosfomycin and imipenem as rescue therapy for MRSA infective endocarditis and complicated bacteremia. METHODS The trial was conducted between 2001 and 2010 in 3 Spanish hospitals. Adult patients with complicated MRSA bacteremia or endocarditis requiring rescue therapy were eligible for the study. Treatment with fosfomycin (2 g/6 hours IV) plus imipenem (1 g/6 hours IV) was started and monitored. The primary efficacy endpoints were percentage of sterile blood cultures at 72 hours and clinical success rate assessed at the test-of-cure visit (45 days after the end of therapy). RESULTS The combination was administered in 12 patients with endocarditis, 2 with vascular graft infection, and 2 with complicated bacteremia. Therapy had previously failed with vancomycin in 9 patients, daptomycin in 2, and sequential antibiotics in 5. Blood cultures were negative 72 hours after the first dose of the combination in all cases. The success rate was 69%, and only 1 of 5 deaths was related to the MRSA infection. Although the combination was safe in most patients (94%), a patient with liver cirrhosis died of multiorgan failure secondary to sodium overload. There were no episodes of breakthrough bacteremia or relapse. CONCLUSIONS Fosfomycin plus imipenem was an effective and safe combination when used as rescue therapy for complicated MRSA bloodstream infections and deserves further clinical evaluation as initial therapy in these infections.

Video-assisted cardioscopy for removal of primary left ventricular myxoma.

Left ventricular myxoma is a rare benign cardiac tumor. Surgical excision is the treatment of choice and completeness of removal is mandatory to avoid late recurrence. A case is presented in which aortic transvalvular video-assisted cardioscopy was used to facilitate removal.

[Mortality and morbidity in HIV-infected patients undergoing coronary artery bypass surgery: a case control study].

The use of highly active antiretroviral therapy (HAART) in patients with HIV infection has improved survival. This improvement combined with the metabolic effects of treatment has increased cardiovascular risk and the need for cardiac surgery in these patients. We compared morbidity and mortality in HIV-infected patients (cases, n=7) and non-HIV-infected patients (controls, n=21) who underwent isolated coronary artery surgery between 1997 and 2004. The durations of extracorporeal circulation and aortic cross-clamping were shorter in HIV-infected patients (P=.002 and P=.014, respectively). The percentage of patients who experienced complications was similar, at 57.1% in both groups, but there was a slightly higher number of complications per patient in non-HIV-infected individuals. The mean length of total hospitalization was greater in HIV-infected patients (27.1 [13.3] versus 8.8 [5.3] days; P=.003), as was that of postoperative hospitalization (18.2 [15.4] vs 7.9 [4.2] days; P=.08). No HIV-infected patient died or needed a repeat cardiac operation. No progression of the HIV infection was observed. Isolated coronary artery surgery in HIV-infected patients produces good results, and there is no increase in morbidity or mortality. Extracorporeal circulation did not influence disease progression.

Morbimortalidad en pacientes con infección por el virus de la inmunodeficiencia humana que reciben cirugía de revascularización miocárdica: estudio de casos y controles

Paciente varón de 64 años al que se realiza coronariografía por angina de esfuerzo con pruebas de isquemia severamente positivas. El estudio mostró una lesión severa focal y calcificada en la coronaria derecha (fig. 1-1). Se intentó evaluarlo con IVUS, pero el catéter no la cruzó, llegándose a visualizar una calcificación superficial de la placa, con extensión angular de unos 300°. Tras dilatar con balón de 3 mm a 18 atm, se logró dilatar la lesión (fig. 1-2), pero en las angiografías de comprobación inmediatamente posteriores se apreciaba una progresiva oclusión del vaso justo distal a la lesión original (fig. 1-3). Se evaluó con IVUS y se obserIMÁGENES EN CARDIOLOGÍA

An Update on Heart Transplantation in Human Immunodeficiency Virus–Infected Patients

Cardiovascular diseases have become a significant cause of morbidity in patients with human immunodeficiency virus (HIV) infection. Heart transplantation (HT) is a well‐established treatment of end‐stage heart failure (ESHF) and is performed in selected HIV‐infected patients in developed countries. Few data are available on the prognosis of HIV‐infected patients undergoing HT in the era of combined antiretroviral therapy (cART) because current evidence is limited to small retrospective cohorts, case series, and case reports. Many HT centers consider HIV infection to be a contraindication for HT; however, in the era of cART, HT recipients with HIV infection seem to achieve satisfactory outcomes without developing HIV‐related events. Consequently, selected HIV‐infected patients with ESHF who are taking effective cART should be considered candidates for HT. The present review provides epidemiological data on ESHF in HIV‐infected patients from all published experience on HT in HIV‐infected patients since the beginning of the epidemic. The practical management of these patients is discussed, with emphasis on the challenging issues that must be addressed in the pretransplant (including HIV criteria) and posttransplant periods. Finally, proposals are made for future management and research priorities.

Long-term Outcome of High-urgency Heart Transplant Patients With and Without Temporary Ventricular Assist Device Support

BACKGROUND The use of short-term ventricular assist devices (VAD) in patients awaiting high-urgency (HU) heart transplantation (HTx) in Spain has steadily increased due to longer waiting times and the new heart allocation system. It is unknown whether the use of short-term VAD support in patients with cardiogenic shock affects HTx outcome. We sought to investigate long-term outcomes of HU transplanted patients with VAD compared with HU transplanted patients without device support. METHODS We retrospectively evaluated all HTx patients transplanted between 1999 and 2011 in our institution. Patients were categorized by urgency: elective HTx, HU-HTx with VAD (status 0), and HU-HTx without VAD (status 1). Actuarial survival rates were compared. RESULTS Of 237 transplanted patients, 55 (23%) were HU-HTx, including 16 on VAD support and 39 without VAD. Mean time in the HU waiting list was 6.5 ± 6 days and mean VAD support was 8.4 ± 8 days (range, 1 to 31 days). Assist devices used were Levitronix Centrimag (6), Abiomed (9), and extracorporeal membrane oxygenation (ECMO) (1). After a mean follow-up of 4.6 ± 4.1 years (range 0 to 13 years), 22 patients had died: 5 VAD and 17 non-VAD. The 1- and 5-year survival rates were 73% and 61% for the VAD and 74% and 62% for the non-VAD group, respectively (P = ns). Kaplan-Meier and Cox regression analyses did not show survival differences, HR 1.11 (95% CI 0.41-3.02), P = 0.84. The presence of renal failure was associated with increased mortality risk, HR 1.9 (95% CI 1.1-3.2), P = 0.02. The presence of renal failure was associated with increased mortality risk [HR 1.9 (95% CI 1.1-3.2), P = .02.). CONCLUSIONS In our experience, the long-term outcome of patients receiving HU-HTx under short-term VAD support is comparable to that of patients undergoing HU-HTx without VAD support. Patients with renal failure had an increased risk for overall mortality in this set of patients.

New Insights in the Management of Cardiogenic Shock Complicating Myocardial Infarction: Role of Urgent Heart Transplantation

OBJECTIVE This study assessed the role of heart transplantation (HTx) in the management of patients with acute myocardial infarction (MI) complicated by refractory cardiogenic shock despite percutaneous coronary intervention (PCI). The primary end-point of the study was mortality at the 1-year follow-up. METHODS Between January 2001 and December 2005, 74 consecutive patients with acute MI complicated with cardiogenic shock were retrospectively analyzed. Thirty-nine patients did not have a contraindication for HTx and qualified for the study (age < 65 years, no comorbidities). RESULTS Urgent HTx was performed in 10 patients. The remaining 29 patients served as controls. The HTx vs no HTx groups were well balanced in age (50 vs 53 years), proportion of multivessel disease (30% vs 10%), cardiac index (2.2 vs 2.4 liters/min/m(2)), and left ventricular ejection fraction (23% vs 25%). Mortality rates were significantly lower in the HTx group, both in the hospital (10% vs 45%, p < 0.03) and at 1 year (10% vs 52%, p < 0.03). Survival at 1 year among patients alive at hospital discharge was 100% in the HTx group vs 94% in the no HTx group. CONCLUSIONS Urgent HTx dramatically improves survival of acute MI patients presenting with refractory cardiogenic shock despite early PCI. Therefore, this approach--wherever feasible--needs to be considered in the management of this particular subset of patients.

Epidemiology, Clinical Features, and Outcome of Infective Endocarditis due to Abiotrophia Species and Granulicatella Species: Report of 76 Cases, 2000–2015

Background Infective endocarditis (IE) caused by Abiotrophia (ABI) and Granulicatella (GRA) species is poorly studied. This work aims to describe and compare the main features of ABI and GRA IE. Methods We performed a retrospective study of 12 IE institutional cases of GRA or ABI and of 64 cases published in the literature (overall, 38 ABI and 38 GRA IE cases). Results ABI/GRA IE represented 1.51% of IE cases in our institution between 2000 and 2015, compared to 0.88% of HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella)-related IE and 16.62% of Viridans group streptococci (VGS) IE. Institutional ABI/GRA IE case characteristics were comparable to that of VGS, but periannular complications were more frequent (P = .008). Congenital heart disease was reported in 4 (10.5%) ABI and in 11 (28.9%) GRA cases (P = .04). Mitral valve was more frequently involved in ABI than in GRA (P < .001). Patient sex, prosthetic IE, aortic involvement, penicillin susceptibility, and surgical treatment were comparable between the genera. New-onset heart failure was the most frequent complication without genera differences (P = .21). Five (13.2%) ABI patients and 2 (5.3%) GRA patients died (P = .23). Factors associated with higher mortality were age (P = .02) and new-onset heart failure (P = .02). The genus (GRA vs ABI) was not associated with higher mortality (P = .23). Conclusions GRA/ABI IE was more prevalent than HACEK IE and approximately one-tenth as prevalent as VGS; periannular complications were more frequent. GRA and ABI genera IE presented similar clinical features and outcomes. Overall mortality was low, and related to age and development of heart failure.

Endocarditis trombótica no bacteriana (Libman-Sacks)

Mujer de 47 anos ingresada en 2002 por ictus. Se diagnostico masa valvular aortica. Se intervino realizandose exeresis de trombo no bacteriano (Fig 1a, b). Durante el estudio de trombofilia fue diagnosticada de sindrome antifosfolipido primario (SAP), inciandose anticoagulacion. Hasta la fecha, ha padecido multiples accidentes cerebrovasculares, isquemicos y hemorragicos. Esta en dialisis peritoneal con probable origen en SAP. SAP es un trastorno autoinmune caracterizado por fenomenos tromboticos iterativos y alargamiento de tiempos de coagulacion. La cirugia cardiaca conlleva morbimortalidad por tromboembolias, suponiendo un reto en el manejo de la circulacion extracorporea. Las complicaciones tromboembolicas son frecuentes durante el seguimiento.

Mechanical Thrombectomy for Acute Ischemic Stroke Secondary to Infective Endocarditis

Intravenous thrombolysis is contraindicated in acute ischemic stroke secondary to infective endocarditis. We report our initial experience in 6 cases of proximal vessel occlusion treated with mechanical thrombectomy, which was safe (no bleeding) and effective (significant early neurological improvement) and might be useful in this clinical setting.