Renee B.A. van den Brink

Comparison of transthoracic and transesophageal color Doppler flow imaging in patients with mechanical prostheses in the mitral valve position

This study determined the relative value of transthoracic and transesophageal color Doppler flow imaging to systolic flow patterns in the left atrium in different types of mechanical prostheses in the mitral valve. Thirty-nine patients were investigated. Based on clinical findings, 36 of 39 patients had normal prosthetic valve function. Seventeen patients were interrogated within a few days after surgery. Systolic regurgitant jets in the left atrium were absent in all patients by both transthoracic pulsed and color Doppler flow imaging. Using transthoracic continuous wave Doppler, however, jets were demonstrated in 8 of 39 patients (21%). Transesophageal color Doppler flow imaging demonstrated systolic regurgitant jets originating from the prosthesis in all patients. Tilting disc valves showed jets during the entire systole (closure and leakage backflow). Each type of prosthesis generated a specific jet pattern. Pathologic regurgitant jets were crescent-shaped, more extensive and turbulent than jets caused by normal closure and leakage backflow. Thus, transthoracic color Doppler flow imaging is not sensitive for detecting regurgitant jets in mechanical prostheses in the mitral valve. All mechanical prostheses show a specific jet pattern, which should be helpful when transesophageal echocardiography is used to identify pathologic backflow.

Effects of changes in management of active infective endocarditis on outcome in a 25-year period

The clinical outcome and long-term follow-up of 130 consecutive patients (141 episodes) with active infective endocarditis who were treated between 1966 and 1991 were analyzed. There was a shift toward a higher proportion of referred patients (39 to 78%), patients aged > 60 years (11 to 41%) and urgent surgical treatment (11 to 44%). Medical treatment was administered in 98 patients (70%); 30-day mortality was 27%. Surgery was performed in 43 patients (30%), with an operative mortality of 26%; 9 of 14 patients (64%) who underwent operation within the first week of admission died. Patients with severe heart failure are at the highest risk for early mortality (relative risk = 21.1; 95% confidence interval 7.4-60.3). Referred patients were much more often treated surgically than were nonreferred patients (48 versus 14%) and had a lower operative mortality (24 vs 30%). Nonreferred patients were more often treated medically (86 vs 52%) and with lower mortality (19 vs 39%). The total follow-up time was 730 patient-years; only 1 patient was considered lost to follow-up. The overall cumulative 5-year and 10-year survival after hospital discharge for patients after urgent surgery were 84 +/- 7% and 53 +/- 7%, respectively, and for those after medical treatment 84 +/- 5% and 77 +/- 6%, respectively. The probability of remaining free of late events (recurrent endocarditis, late valve replacement or death) during 5 and 10 years for patients after urgent surgery was 84 +/- 7% and 53 +/- 15%, respectively, and for those after medical treatment 59 +/- 6% and 40 +/- 7%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic Value of Biventricular Function in Hypotensive Patients After Cardiac Surgery as Assessed by Transesophageal Echocardiography

In patients after cardiac surgery, hypotension, defined as a mean arterial pressure less than 65 mmHg despite adequate filling pressures and positive inotropic medication, poses a problem. In addition, it is often difficult to determine whether these patients have suffered irreversible myocardial injury or if they are likely to recover. In this study, left and right ventricular function, as assessed by transesophageal echocardiography (TEE), was related to mortality both (1) quantitatively, using fractional area change (FAC), and (2) qualitatively, using a segmental wall motion analysis, which assigned a score to myocardial wall segments, in order to determine whether this technique can be used to predict survival. Mortality rate was very high in patients with biventricular and especially right ventricular failure (FAC less than 35%). Left and right ventricular wall motion abnormality indices were significantly better in survivors compared to nonsurvivors, but no distinct cut-off value could be determined. A wall motion index derived from only 6 segments at the mid-papillary muscle level was found to be as reliable as one based on 16 segments of the entire left ventricle. Thus, TEE provided information about the degree of left and right ventricular dysfunction by using a single cross-section at the papillary muscle level. It identified patients at high risk of death, ie, those with compromised right and biventricular function.

Cardiac dysfunction after aneurysmal subarachnoid hemorrhage: Relationship with outcome

Objective: To assess whether cardiac abnormalities after aneurysmal subarachnoid hemorrhage (aSAH) are associated with delayed cerebral ischemia (DCI) and clinical outcome, independent from known clinical risk factors for these outcomes. Methods: In a prospective, multicenter cohort study, we performed echocardiography and ECG and measured biochemical markers for myocardial damage in patients with aSAH. Outcomes were DCI, death, and poor clinical outcome (death or dependency for activities of daily living) at 3 months. With multivariable Poisson regression analysis, we calculated risk ratios (RRs) with corresponding 95% confidence intervals. We used survival analysis to assess cumulative percentage of death in patients with and without echocardiographic wall motion abnormalities (WMAs). Results: We included 301 patients with a mean age of 57 years; 70% were women. A wall motion score index ≥1.2 had an adjusted RR of 1.2 (0.9–1.6) for DCI, 1.9 (1.1–3.3) for death, and 1.8 (1.1–3.0) for poor outcome. Midventricular WMAs had adjusted RRs of 1.1 (0.8–1.4) for DCI, 2.3 (1.4–3.8) for death, and 2.2 (1.4–3.5) for poor outcome. For apical WMAs, adjusted RRs were 1.3 (1.1–1.7) for DCI, 1.5 (0.8–2.7) for death, and 1.4 (0.8–2.5) for poor outcome. Elevated troponin T levels, ST-segment changes, and low voltage on the admission ECGs had a univariable association with death but were not independent predictors for outcome. Conclusion: WMAs are independent risk factors for clinical outcome after aSAH. This relation is partly explained by a higher risk of DCI. Further study should aim at treatment strategies for these aSAH-related cardiac abnormalities to improve clinical outcome.

Diagnostic evaluation of left-sided prosthetic heart valve dysfunction

Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context.

Right ventricular dysfunction is an independent predictor for mortality in ST‐elevation myocardial infarction patients presenting with cardiogenic shock on admission

Despite improvement in prognosis for ST‐elevation myocardial infarction (STEMI) patients, mortality remains high in STEMI patients presenting with cardiogenic shock (CS). Right ventricular (RV) dysfunction is an established independent predictor for adverse prognosis in STEMI patients without CS. The purpose of our study was to determine the prognostic value of RV dysfunction on admission in STEMI patients presenting in CS.

CT Angiography and 18F-FDG-PET Fusion Imaging for Prosthetic Heart Valve Endocarditis

IN PROSTHETIC HEART VALVE (PHV) ENDOCARDITIS, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) may occasionally fail to recognize vegetations and periannular extensions (abscesses/mycotic aneurysms) due to acoustic shadowing by the metal PHV ring [(1)][1]. In

Health-Related Quality of Life and Posttraumatic Stress Disorder among Survivors of Left-Sided Native Valve Endocarditis

BACKGROUND The long-term prognosis of endocarditis is described primarily in relation to clinical outcome measures-for example, such complications as cerebrovascular accident, cardiac failure, need for cardiac surgery, relapse rate, and mortality. To our knowledge, to date, no studies have examined the health-related quality of life and the prevalence of long-term persistence of physical symptoms for survivors of left-sided native valve endocarditis. METHODS We conducted a prospective follow-up study of patients treated for left-sided native valve endocarditis from 1 November 2000 through 31 October 2003 in 23 hospitals in the Netherlands. Of 86 patients eligible to participate, 55 completed questionnaires administered 3 m and 12 m after discharge; an additional 12 patients completed questionnaires 12 m after discharge only, making a total of 67 patients in our study. Persistence of symptoms and employment status were recorded. The health-related quality of life was measured by using the Dutch version of the Medical Outcomes Study Short Form 36-item health survey and the Posttraumatic Stress Disorder questionnaire. RESULTS Three months after the end of antimicrobial treatment, 41 (75%) of 55 patients still had physical symptoms. Twelve months after the end of antimicrobial treatment, 36 (54%) of 67 patients still had physical symptoms. Before the episode of endocarditis, 30 (81%) of 37 patients aged < or =60 years were employed and working. At 3 m follow-up, 16 (52%) of 31 patients returned to work, and at 12 m follow-up, 24 (65%) of 37 patients were working. One year after discharge, the health-related quality of life was impaired in 5 of 8 dimensions, compared with age-adjusted standard values, and 7 (11%) of 64 patients suffered from posttraumatic stress disorder. CONCLUSIONS A year after discharge, most survivors of left-sided native valve endocarditis still had persisting symptoms and a seriously diminished quality of life, and 11% of patients suffered from posttraumatic stress disorder.

Prognostic Value of Serial C-Reactive Protein Measurements in Left-Sided Native Valve Endocarditis

BACKGROUND The clinical course of left-sided native valve infective endocarditis varies from uncomplicated disease to fulminant infection. Although several factors are known to affect clinical outcome, it is difficult to predict morbidity and mortality in individual patients. The objective of this study was to determine the value of serial C-reactive protein (CRP) measurements as a predictor of clinical outcome. METHODS One hundred twenty-three consecutive patients who fulfilled the Duke criteria for definite left-sided native valve infective endocarditis were prospectively enrolled. Poor outcome was defined as serious infectious complications or death. Patients were followed up for 12 weeks after the end of antimicrobial therapy. Multivariate analysis was used to examine the relative importance of the CRP level as a predictor of poor outcome after adjusting for age, abscess, multivalvular involvement, and Staphylococcus aureus infection. RESULTS After 1 week of therapy, the adjusted odds ratio for poor outcome was 10.3 (95% confidence interval, 2.2-49.4) for patients with CRP levels in the highest tertile (>122 mg/L [to convert to nanomoles per liter, multiply by 9.524]) vs the lowest tertile (1-69 mg/L). A low percentage decline during the first week of treatment was statistically significantly associated with a higher risk of poor outcome (logistic regression coefficient, 1.1; P = .009). At no point in time did CRP level predict the need for cardiac surgery. CONCLUSION High CRP level after 1 week of treatment and a slow percentage decline in CRP level during the first week of treatment are indicators of poor clinical outcome.

Comparison of transthoracic and transesophageal echocardiography with surgical findings in mitral regurgitation

This prospective study was conducted to ascertain whether echocardiographic evaluation could provide more insight into the genesis of mitral regurgitation (MR) before surgery. All patients underwent preoperative transthoracic and transesophageal echocardiography. Nine centers participated in the ESMIR (Echocardiographic Selection of patients for MItral valve Reconstruction) study and 350 patients were included. Compared with surgical findings, the percentage of functional abnormalities correctly predicted by both echo modalities was highest in patients with increased leaflet mobility (83% for transthoracic and 86% transesophageal echocardiography). In contrast, in normal leaflet mobility, the prediction was better by transthoracic than by transesophageal echocardiography (75% vs 64%). In patients with restricted leaflet mobility, the predictive value of both techniques was similar. The diagnostic yield of anatomic abnormalities of both echo techniques was similar, except for chordal rupture; a sensitivity by transesophageal echocardiography of 79% and by transthoracic echocardiography of 57% (p < 0.001). In general, the sensitivity of each echo technique for detecting anatomic abnormalities was <70%, except for annular dilatation, leaflet thickening, and chordal rupture. At surgery, the prevailing functional condition was increased leaflet mobility (42%). The conclusion is that both echo techniques provide adequate information regarding the functional condition of the mitral valve apparatus, not withstanding limitations in assessing anatomic details. Transthoracic echocardiography appears to be sufficient for preoperative evaluation of MR.