Toufik Mahfood Haddad

Early versus late surgical intervention or medical management for infective endocarditis: A systematic review and meta-analysis

Objective Infective endocarditis is associated with high morbidity and mortality and optimal timing for surgical intervention is unclear. We performed a systematic review and meta-analysis to compare early surgical intervention with conservative therapy in patients with infective endocarditis. Methods PubMed, Cochrane, EMBASE, CINAHL and Google-scholar databases were searched from January 1960 to April 2015. Randomised controlled trials, retrospective cohorts and prospective observational studies comparing outcomes between early surgery at 20 days or less and conservative management for infective endocarditis were analysed. Results A total of 21 studies were included. OR of all-cause mortality for early surgery was 0.61 (95% CI 0.50 to 0.74, p<0.001) in unmatched groups and 0.41 (95% CI 0.31 to 0.54, p<0.001) in the propensity-matched groups (matched for baseline variables). For patients who had surgical intervention at 7 days or less, OR of all-cause mortality was 0.61 (95% CI 0.39 to 0.96, p=0.034) and in those who had surgical intervention within 8–20 days, the OR of mortality was 0.64 (95% CI 0.48 to 0.86, p=0.003) compared with conservative management. In propensity-matched groups, the OR of mortality in patients with surgical intervention at 7 days or less was 0.30 (95% CI 0.16 to 0.54, p<0.001) and in the subgroup of patients who underwent surgery between 8 and 20 days was 0.51 (95% CI 0.35 to 0.72, p<0.001). There was no significant difference in in-hospital mortality, embolisation, heart failure and recurrence of endocarditis between the overall unmatched cohorts. Conclusion The results of our meta-analysis suggest that early surgical intervention is associated with significantly lower risk of mortality in patients with infective endocarditis.

Cardiac Rehabilitation in Patients With Left Ventricular Assist Device: A SYSTEMATIC REVIEW AND META-ANALYSIS

Purpose: Exercise-based cardiac rehabilitation (EBCR) has been demonstrated to improve functional capacity in heart failure (HF). However, there are limited data on the effect of EBCR in patients with advanced HF and left ventricular assist devices (LVADs). This meta-analysis sought to evaluate the effects of EBCR on functional capacity in patients with LVAD. Methods: PubMed, Web of Science, CINAHL, and Cochrane Library databases were searched for randomized studies assessing the impact of EBCR in patients following LVAD implantation compared with standard therapy (ST). Using pre-defined criteria, appropriate studies were identified and selected. Data from selected studies were extracted in a standardized fashion and a meta-analysis was performed using a random-effects model with DerSimonian Liard weighting. Analysis employed weighted mean difference (WMD) as the effect size and intention-to-treat (ITT) principle. Study quality, publication bias, and heterogeneity were assessed. Results: Six trials with a total of 183 patients (EBCR: 125; ST: 58) were identified. Mean age was 51 years and 83% were males. The initiation of EBCR varied from LVAD implantation during the index hospitalization to 10 mo post-LVAD implantation. The median rehabilitation period ranged from 6 to 10 wk. Exercise-based cardiac rehabilitation was associated with improved peak oxygen uptake ( O2) in all trials. Quantitative analysis was performed on 3 randomized studies involving 61 patients (EBCR = 39, ST = 22). Exercise-based cardiac rehabilitation was associated with significantly greater peak O2 (WMD: 3.00 mL/kg/min; 95% CI: 0.64-5.35, P = .001). Similarly, 6-minute walk distance (6MWD) showed significantly greater improvement in the EBCR group than in the ST group (WMD: 60.06 m; 95% CI, 22.61-97.50, P = .002). Heterogeneity was low among the included trials. Exclusion sensitivity and per-protocol analysis demonstrated results consistent with ITT analysis. None of the included studies reported serious adverse events related to EBCR, which supports the safety of EBCR after LVAD implantation. Conclusion: This systematic review and meta-analysis demonstrated that EBCR following LVAD implantation is associated with greater improvement in functional capacity compared with ST as reflected by improved peak O2 and 6MWD. However, given the small number of patients, further research into the clinical impact of EBCR in LVAD patients is necessary.

Acute Amiodarone Pulmonary Toxicity after Drug Holiday: A Case Report and Review of the Literature

Amiodarone is reported to cause a wide continuum of serious clinical effects. It is often challenging to detect Amiodarone-induced pulmonary toxicity (AIPT). Typically, the diagnosis is made based on the clinical settings and may be supported by histopathology results, if available. We describe a 57-year-old patient who developed severe rapidly progressive respiratory failure secondary to AIPT with acute bilateral infiltrates and nodular opacities on chest imaging. Interestingly, Amiodarone was discontinued 3 weeks prior to his presentation. He had normal cardiac filling pressures confirmed by echocardiography. To our knowledge, this is the first case of isolated acute lung injury induced by Amiodarone, three weeks after therapy cessation, with adequate clinical improvement after supportive management and high dose steroid therapy.

Meta-analysis of Randomized Controlled Trials on Patent Foramen Ovale Closure Versus Medical Therapy for Secondary Prevention of Cryptogenic Stroke

The optimal management of patients with cryptogenic stroke (CS) and patent foramen ovale (PFO) remains controversial. We conducted a meta-analysis to assess the effect of PFO closure for secondary prevention of stroke on patients with CS. We searched the literature for randomized control trials assessing the recurrence of stroke after PFO closure compared with medical therapy (antiplatelet and/or anticoagulation). Five randomized control trials with a total of 3,440 patients were included. The mean age was 45.2 ± 9.7 years and follow-up duration ranged from 2.0 to 5.9 years. PFO closure significantly reduced the risk of stroke compared with the medical therapy (2.8% vs 5.8%; relative risk [RR] 0.48, confidence interval [CI] 0.27 to 0.87, p = 0.01, I2 = 56%). The number needed to treat for stroke prevention was 10.5. PFO closure was associated with an increased risk of atrial fibrillation compared with medical therapy (4.2% vs 0.7%; RR 4.55, CI 2.16 to 9.6, p = 0.0001, I2 = 25%). There was no significant difference in all-cause mortality (RR 1.33, CI 0.56 to 3.16, p = 0.52, I2 = 0%), as well as no difference in bleeding risk between the 2 groups (RR 0.94, CI 0.49 to 1.83, p = 0.86, I2 = 29%). In conclusion, our meta-analysis demonstrates that PFO closure is associated with significantly lower risk of recurrent stroke in patients with PFO and CS compared with medical therapy. However, atrial fibrillation was more common among closure patients.

Influence of Left Ventricular Hypertrophy on In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

ABSTRACT Left ventricular hypertrophy (LVH) is associated with worse outcomes in chronic obstructive pulmonary disease (COPD); however, its role in an acute exacerbation of COPD (AECOPD) has not been reported. This was a retrospective cohort study during 2008–2012 at an academic medical center. AECOPD patients >18 years with available echocardiographic data were included. LVH was defined as LV mass index (LVMI) >95 g/m2 (women) and >115g/m2 (men). Relative wall thickness was used to classify LVH as concentric (>0.42) or eccentric (<0.42). Outcomes included need for and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed p < 0.05 was considered statistically significant. Of 802 patients with AECOPD, 615 patients with 264 (42.9%) having LVH were included. The LVH cohort had higher LVMI (141.1 ± 39.4 g/m2 vs. 79.7 ± 19.1 g/m2; p < 0.001) and lower LV ejection fraction (44.5±21.9% vs. 50.0±21.6%; p ≤ 0.001). The LVH cohort had statistically non-significant longer ICU LOS, and higher NIV and MV use and duration. Of the 264 LVH patients, concentric LVH (198; 75.0%) was predictive of greater NIV use [82 (41.4%) vs. 16 (24.2%), p = 0.01] and duration (1.0 ± 1.9 vs. 0.6 ± 1.4 days, p = 0.01) compared to eccentric LVH. Concentric LVH remained independently associated with NIV use and duration. In-hospital outcomes in patients with AECOPD were comparable in patients with and without LVH. Patients with concentric LVH had higher NIV need and duration in comparison to eccentric LVH.

Tricuspid and mitral endocarditis due to methicillin-resistant Staphylococcus aureus exhibiting vancomycin-creep phenomenon

Right-sided infective endocarditis (RIE) is commonly due to Staphylococcus aureus and often involves the tricuspid valve (TV). A 31-year-old man with prior intravenous drug use presented with substernal pain, cough, dyspnoea and fever. Examination revealed a febrile, tachycardic male with peripheral infective endocarditis stigmata and right-heart failure. Laboratory parameters demonstrated leucocytosis, lactic acidosis and methicillin-resistant S. aureus (MRSA) bacteraemia. Echocardiography demonstrated multiple TV echodensities and chest imaging confirmed septic emboli. The MRSA species demonstrated ‘vancomycin-creep’, necessitating therapy with daptomycin and ceftaroline. Owing to persistent bacteraemia and septic shock, the patient underwent TV surgery, but continued to have a poor postoperative course with subsequent death. Indications for surgical therapy of RIE are limited to the European guidelines and most data are extrapolated from left-heart disease. MRSA exhibiting vancomycin-creep portends a poorer prognosis and requires aggressive therapy. We advocate the use of ceftaroline salvage therapy with daptomycin, pending further trials.

Fatal Case of Probable Invasive Aspergillosis after Five Years of Heart Transplant: A Case Report and Review of the Literature

Invasive fungal infections are very common in solid organ transplants and occur most frequently in the first three months after transplant. A 49-year-old female with a history of two remote heart transplants with the most recent one occurring 5 years ago was admitted for increasing shortness of breath, cough, and fever. Computerized tomography (CT) scan of the chest showed left lower lung ground-glass and tree-in-bud opacities. She was started on broad spectrum antibiotics along with ganciclovir and micafungin. Ganciclovir was added due to the patients past history of CMV infection and empiric fungal coverage with micafungin. Bronchoalveolar lavage (BAL) was performed as her respiratory status worsened and voriconazole was added for possible aspergillosis in combination therapy with micafungin. BAL galactomannan returned positive which was suggestive of aspergillosis. Patient worsened clinically and subsequently succumbed to cardiorespiratory arrest despite our best efforts. It is important to have a high degree of clinical suspicion for invasive aspergillosis in transplant patients even many years after transplant and initiate aggressive therapy due to poor outcomes.

Early Repolarization Found on Routine Electrocardiograms: Risk and Management

Early repolarization (ER) pattern is a prominent J point (end-QRS notch or slur) with an elevation ≥0.1 mV in two or more contiguous leads (excluding V1-V3) in a 12-lead electrocardiogram (ECG). Furthermore, the QRS duration is required to be <120 ms (measured in leads in which J point elevation

Role of B-Type Natriuretic Peptide in Predicting In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Preserved Left Ventricular Function A 5-Year Retrospective Analysis

Background: The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). Methods: This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. Results: Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. Conclusion: Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.

A Case of Amitriptyline-induced Myocarditis

Amitriptyline is a widely prescribed tricyclic antidepressant (TCA) with a very concerning cardiotoxicity profile, but it is one that has not been discussed much in literature. Here, we present a case of amitriptyline toxicity presenting as myocarditis with pericardial involvement. A 21-year-old male with no previous cardiac history presented to the emergency department (ED) with a decreased level of consciousness after an amitriptyline overdose as a suicidal attempt. For concerns with airway protection, the patient was intubated and subsequently admitted to the intensive care unit (ICU). An electrocardiogram (EKG) showed sinus tachycardia, prolonged QRS complex, prolonged QTc interval, and nonspecific ST-T wave changes. Intravenous fluid resuscitation and sodium bicarbonate were administered with a target blood pH of 7.5 to 7.55. Two days later, the patient was taken off mechanical ventilation and improved clinically. However, troponin levels began to rise with a peak level of 4.08 µg/L. He then began having fevers, elevated white blood cell counts (WBCs), and elevated inflammatory markers. Transthoracic echo (TTE) revealed an ejection fraction (EF) of 45%-50%, no wall segment motion abnormalities, and a mild-to-moderate pericardial effusion. Cardiac magnetic resonance (CMR) was done, which revealed changes indicative of acute myocarditis, moderate pericardial effusion, a calculated EF of 45% with a moderate left ventricular dilation, and no coronary artery stenosis or anomalous coronary artery origin. Given the patient’s age, the absence of cardiac risk factors, and the presence of an amitriptyline overdose along with his EKG, TTE, and CMR findings, we hypothesize that this myocarditis with pericardial involvement is due to amitriptyline-induced direct toxicity.