Sébastien Renard

The timing of surgery influences mortality and morbidity in adults with severe complicated infective endocarditis: a propensity analysis

AIMS To determine whether the timing of surgery could influence mortality and morbidity in adults with complicated infective endocarditis (IE). METHODS AND RESULTS In 291 consecutive adults with definite IE who underwent surgery during the active phase, we compared those operated on within the first week of antimicrobial therapy (n=95) to those operated on later (n=191). The impact of the timing of surgery on 6-month mortality, relapses, and postoperative valvular dysfunctions (PVD) was analysed using propensity score (PS) analyses. After stratification of the cohort into quintiles based on the PS, ≤1st week surgery was associated with a trend of decrease in 6-month mortality in the quintile of patients with the most likelihood of undergoing this early surgical management [quintile 5: 11% vs. 33%, odds ratio (OR)=0.18, 95% CI (confidence interval) 0.04-0.83, P=0.03]. Patients of this subgroup were younger, were more likely to have Staphylococcus aureus infections, congestive heart failure, and larger vegetations. Besides, ≤1st week surgery was associated with an increased number of relapses or PVD (16% vs. 4%, adjusted OR=2.9, 95% CI 0.99-8.40, P=0.05). CONCLUSION Surgery performed very early may improve survival in patients with the most severe complicated IE. However, a greater risk of relapses and PVD should be expected when surgery is performed very early.

Excess mortality and morbidity in patients surviving infective endocarditis

BACKGROUND Mortality and morbidity associated with infective endocarditis may extend beyond successful treatment. The primary objective was to analyze rates, temporal changes, and predictors of excess mortality in patients surviving the acute phase of endocarditis. The secondary objective was to determine the rate of recurrence and the need for late cardiac surgery. METHODS An observational cohort study was conducted at a university-affiliated tertiary medical center, among 328 patients who survived the active phase of endocarditis. We used age-, sex-, and calendar year-specific mortality hazard rates of the Bouches-du-Rhone French district population to calculate expected survival and excess mortality. The risk of recurrence and late valve surgery was also assessed. RESULT Compared with expected survival, patients surviving a first episode of endocarditis had significantly worse outcomes (P = .001). The relative survival rates at 1, 3, and 5 years were 92% (95% CI, 88%-95%), 86% (95% CI, 77%-92%), and 82% (95% CI, 59%-91%), respectively. This excess mortality was observed during the entire follow-up period but was the highest during the first year after hospital discharge. Most of the recurrences and late cardiac surgeries also occurred during this period. Women exhibited a higher risk of age-adjusted excess mortality (adjusted excess hazard ratio, 2.0; 95% CI, 1.05-3.82; P = .03). Comorbidity index, recurrence of endocarditis, and history of an aortic valve endocarditis in women were independent predictors of excess mortality. CONCLUSIONS These results justify close monitoring of patients after successful treatment of endocarditis, at least during the first year. Special attention should be paid to women with aortic valve damage.

Pim-1: A new biomarker in pulmonary arterial hypertension

Provirus integration site for Moloney murine leukemia virus (Pim-1) is an oncoprotein overexpressed in lungs from pulmonary arterial hypertension (PAH) patients and involved in cell proliferation via the activation of the NFAT/STAT3 signaling pathway. We hypothesized that Pim-1 plasma levels would predict the presence of PAH and correlate with disease severity. Pim-1 plasma levels were measured at the time of catheterization in 49 PAH patients, including nonvasoreactive (n = 19) and vasoreactive idiopathic PAH (n = 5), and PAH related to connective tissue disease (n = 16) and congenital heart disease (n = 9). Fifty controls were also recruited. The capacity of Pim-1 to discriminate PAH from controls and its association with disease severity were assessed. Pim-1 plasma levels were higher in PAH than in controls (9.6 ± 4.0 vs. 7.2 ± 2.4 ng/mL, P > 0.01). Pim-1 appropriately discriminated proliferative PAH from controls (AUC = 0.78 to 0.94 using ROC curves). Among PAH patients, Pim-1 correlated with traditional markers of PAH severity. The 1-year survival was 97% and 47% for PAH patients with baseline Pim-1 levels lower and higher than 11.1 ng/mL, respectively (HR 11.4 (3.3-39.7); P > 0.01). After adjustment for hemodynamic and biochemical variables, Pim-1 levels remained an independent predictor of mortality (P > 0.01). Pim-1 is a promising new biomarker in PAH.

Severe Pulmonary Arterial Hypertension in Patients Treated for Hepatitis C With Sofosbuvir

Development of direct-acting antiviral agents against hepatitis C virus (HCV) has changed the management of chronic HCV infection. We report three cases of newly diagnosed or exacerbated pulmonary arterial hypertension (PAH) in patients treated with sofosbuvir. All patients had PAH-associated comorbidities (HIV coinfection in two, portal hypertension in one) and one was already being treated for PAH. At admission, all patients presented with syncope, World Health Organization functional class IV, right-sided heart failure, and extremely severe hemodynamic parameters. After specific PAH therapy, the clinical and hemodynamic properties for all patients were improved. Severity and acuteness of PAH, as well as chronology, could suggest a causal link between HCV treatment and PAH onset. We hypothesize that suppression of HCV replication promotes a decrease in vasodilatory inflammatory mediators leading to worsening of underlying PAH. The current report suggests that sofosbuvir-based therapy may be associated with severe PAH.

Massive Biventricular Thrombosis as a Consequence of Myocarditis Findings From 2-Dimensional and Real-Time 3-Dimensional Echocardiography

A43-year-old man with medical history of gastroenteritis 2 weeks previously was referred to our intensive care unit for acute chest pain. At admission, the ECG showed negative T waves in V1, V2, V3, and V4 leads, and his troponin serum level was 0.6 ng/mL. His C-reactive protein level was elevated at 70 mg/L, and the serum blood count showed hyperleukocytosis with hyperlymphocytosis and thrombocytosis. Two-dimensional transthoracic echocardiogram revealed a dilated and hypokinetic left ventricle (LV) and a biventricular thrombosis (Figure 1). A dramatic and mobile apical thrombus appeared in the LV cavity; a smaller one near to the septo-basal wall was better assessed by real-time, 3-dimensional transthoracic echocardiogram (Figure 2, Movie I, and Movie II). Another thrombus was observed in the apex of the right ventricle (Figure 2, Movie III). Abdominal computed tomography scan revealed a massive splenic infarction that explained the thrombocytosis. The coronary angiogram was normal. Facing a large and mobile LV apical thrombus and a high risk of new embolization, we performed a total thrombectomy in an urgent setting through an aortotomy and both a left and right atriotomy. Despite an early postoperative recurrence of a small LV thrombus, the outcome was favorable, with disappearance of this thrombus after anticoagulation therapy, spontaneous resolution of the inflammatory syndrome, and an improvement in LV function. The presumptive final diagnosis was myocarditis complicated by biventricular thrombosis.A 43-year-old man with medical history of gastroenteritis 2 weeks previously was referred to our intensive care unit for acute chest pain. At admission, the ECG showed negative T waves in V1, V2, V3, and V4 leads, and his troponin serum level was 0.6 ng/mL. His C-reactive protein level was elevated at 70 mg/L, and the serum blood count showed hyperleukocytosis with hyperlymphocytosis and thrombocytosis. Two-dimensional transthoracic echocardiogram revealed a dilated and …

Life span of patients with Eisenmenger syndrome is not superior to that of patients with other causes of pulmonary hypertension

BACKGROUND Patients with Eisenmenger syndrome (ES) carry a better prognosis from diagnosis than patients with other causes of pulmonary hypertension (PH), but their life span has not yet been clarified. AIMS To clarify both survival from diagnosis and life span in ES, and in closed shunt with pulmonary arterial hypertension (PAH), as compared with other causes of PH. METHODS Data on all adult patients with PH attending our centre over the past decade was collected. Outcome was defined as death or transplantation. RESULTS We studied 149 patients, including 30 (20%) patients with ES and 12 (8%) patients with closed shunt with PAH. Median age at diagnosis was lower for patients with ES and closed-shunt with PAH compared to patients with other causes of PH (P<0.001 and P=0.008 respectively). Median follow-up was 4.25 years. Survival from diagnosis was longer in ES compared to other causes of PH (logrank; P=0.02) and similar between closed-shunt with PAH and other causes of PH (logrank; P=0.3). Survival rates at 3, 6 and 9 years from diagnosis were: 73%, 50% and 47% for ES, 75%, 25% and 0% for closed-shunt with PAH, 65%, 23% and 9% for other causes of PH. Life span was similar in those three groups (logrank; P=0.2 and P=0.7, respectively). CONCLUSIONS Life span is similar in patients with ES, with a closed-shunt associated with PAH, and in patients with other causes of PH.

Eclipsed Mitral Regurgitation: A New Form of Functional Mitral Regurgitation for an Unusual Cause of Heart Failure with Normal Ejection Fraction

Background: Transient functional mitral regurgitation (MR) has never been reported as a cause of heart failure (HF) with normal ejection fraction (EF) in the absence of epicardial coronary artery stenosis. Results: Performance of echocardiography in patients with acute HF before initiation of HF medical treatment allowed identification of three patients with normal EF but transient massive functional MR during the HF episode. In all patients, massive MR occurred as a consequence of sudden extreme apical tenting of both leaflets with total lack of coaptation, despite normal EF and absence of detectable left ventricular (LV) remodeling, and despite absence of significant stenosis on coronary arteries. In all patients MR was triggered by methylergonovine injection and was reversible either spontaneously or after nitroglycerine administration, leaving patients with normal echocardiogram between HF episodes. In two patients, long-term administration of calcium channel blockers prevented recurrences of MR and HF, whereas in one, mitral valve was eventually replaced. Conclusion: Sudden reversible apical tenting of mitral leaflets with subsequent torrential MR and acute HF can occur despite normal EF, absence of pre-existing LV remodeling and absence of coronary artery stenosis. This atypical type of functional MR is an unusual mechanism of HF in patients with normal LVEF.

Infective endocarditis in octogenarians

Objective To describe the characteristics of infective endocarditis (IE) in octogenarians and assess their prognosis. Methods Patients with definite IE hospitalised at a referral centre between July 2008 and July 2013 were prospectively included. A total of 454 patients were divided into three groups: 230 patients under 65 years old, 173 patients between 65 and 80 years old, and 51 patients over 80 years old. The main end point was 1-year mortality. Results One-year mortality was higher in the ≥80 years old group (37.3%) than in the <65 years old group (13%; p<0.001) and the 65–80 years old group (19.7%; p=0.009). Enterococci and Streptococcus gallolyticus were the more frequent micro-organisms. Embolism under antibiotic therapy (n=11 (21.6%), p=0.03) and renal failure (n=23 (51%), p=0.004) were more frequent in the ≥80 years old group. Among the ≥80 years old group, 38 patients had theoretical indication for surgery. Mortality was low (6.3%) in the 16 operated patients, but very high (72.7%) in the 22 patients not operated. Even if octogenarians were less often operated, their survival after surgery was excellent like younger patients (93.7%, 89.9% and 90.4%, respectively), whereas the absence of surgery was associated with very poor prognosis. Conclusions IE in octogenarians is a different disease, with Enterococci as the most frequent micro-organisms and with higher mortality than younger patients. ESC recommendations for surgery are less implemented than in younger patients, yielding dramatic mortality in patients not operated despite a theoretical indication for surgery, while operated patients have an excellent prognosis. These results suggest that surgery is underused in octogenarians.

Pacemaker Lead Vegetation Trapped in Patent Foramen Ovale A Cause of Hypoxemia After Percutaneous Extraction

A 71-year-old man was admitted to our department with suspected pacemaker endocarditis because of unexplained fever and Staphylococcus epidermidis bacteremia. The patient’s history revealed a double-chamber pacemaker implantation 7 years ago for third-degree atrioventricular block. Transesophageal echocardiography showed a significant thickening of both leads associated with a mobile 2.7-cm vegetation on the ventricular lead. A patent foramen ovale was also noted on transesophageal echocardiography (Figure 1; supplemental Movie I). The diagnosis of endocarditis was thus confirmed, and percutaneous lead extraction was planned under antibiotic therapy with prior epicardial implantation. The extraction procedure was performed by lead traction associated with a laser sheath for both the auricular and ventricular leads. The immediate …A 71-year-old man was admitted to our department with suspected pacemaker endocarditis because of unexplained fever and Staphylococcus epidermidis bacteremia. The patient’s history revealed a double-chamber pacemaker implantation 7 years ago for third-degree atrioventricular block. Transesophageal echocardiography showed a significant thickening of both leads associated with a mobile 2.7-cm vegetation on the ventricular lead. A patent foramen ovale was also noted on transesophageal echocardiography (Figure 1; supplemental Movie I). The diagnosis of endocarditis was thus confirmed, and percutaneous lead extraction was planned under antibiotic therapy with prior epicardial implantation. The extraction procedure was performed by lead traction associated with a laser sheath for both the auricular and ventricular leads. The immediate …

Ventricular Septal Rupture After a Nonpenetrating Chest Trauma Findings From Real-Time Three-Dimensional Echocardiography and Cardiac Magnetic Resonance

A 19-year-old man with no medical history was involved in a motorcycle accident with chest trauma and rapid deceleration. No injury was apparent initially, but 3 weeks later, he developed dyspnea and was referred to our echocardiography unit for assessment of a new 4/6 systolic heart murmur. 2D echocardiography (Figure 1) and cardiac magnetic resonance (CMR) …