Extracardiac Complications Research Articles

Postoperative complications and association with outcomes in pediatric cardiac surgery

Our primary aim was to study postoperative complications in pediatric cardiac surgery patients and their association with cardiopulmonary bypass (CPB) use. The secondary aim was to evaluate the association of postoperative complications with established outcome measures. A single-institution retrospective observational study was undertaken of consecutive pediatric cardiac surgery patients during a 1-year period. Five cardiac and 15 extracardiac complications were studied. CPB use, CPB parameters, demographics, and Risk Adjusted Classification for Congenital Heart Surgery (RACHS-1) levels were evaluated as risk factors for complications. Outcomes, including mechanical ventilation duration, pediatric cardiac intensive care unit stay, hospital stay, and mortality were studied. A total of 325 patients were studied: 271 with CPB and 54 without CPB. Of the 325 patients, 141 (43%) had ≥1 complication (95% confidence interval, 38%-49%). Of the 325 patients, 82 (25%) developed cardiac and 120 (37%) developed extracardiac complications. The evidence from logistic regression analysis was insufficient to suggest a relationship between CPB support and the incidence of cardiac or extracardiac complications after adjusting for age, gender, previous sternotomy, and RACHS-1 levels. For patients receiving CPB, longer CPB times, higher RACHS-1 levels, and a lower temperature with CPB were associated with a greater number of cardiac complications (P<.01). Longer CPB times and higher RACHS-1 levels were associated with a greater number of extracardiac complications (P=.006). Postoperative complications were significantly associated with an increased mechanical ventilation duration, pediatric cardiac intensive care unit stay, and hospital stay and mortality (P<.01). Postoperative complications occurred in 43% of pediatric cardiac surgeries performed both with and without CPB. The complications were associated with longer mechanical ventilation and pediatric cardiac intensive care unit and hospital stays, and increased mortality.

Gastroparesis: an under-recognized complication after atrial fibrillation catheter ablation procedure

Purpose: Percutaneous catheter ablation (CA) is a well-established treatment for symptomatic atrial fibrillation (AF). Major complications occur in up to 6% of procedures, being mostly cardiovascular events. Among extracardiac complications, only a few cases of gastroparesis have been reported. We present two cases of gastroparesis after CA. Methods: Patients with AF undergoing CA with radiofrecuency (RF) or cryoablation therapy (CrT) were consecutively included. CrT was performed in those patients with normal anatomy of pulmonary veins (PV) and paroxysmal AF, and the rest of the patients underwent RF CA. Results: From May 2011 to December 2012 a total of 106 procedures were performed (80 RF and 26 CrT procedures). Mean age was 63,6years, 63% were male. AF was persistent in 48% of cases. The incidence of gastroparesis was 1.88% (2/106). Patients complained of shortness of breath, dysphagia, early satiety and epigastric discomfort within 72-96 hours after CA. RF standard CA was performed in both cases (a 3.5-mm irrigated catheter with up to 35 W in a temperature-controlled, power limited mode). CT scan excluded atrio-esophageal fistula and showed a marked gastric dilatation and remnants of food (figure). A gastric emptying study was diagnostic of gastroparesis. Management was conservative with pro-kinetic therapy, proton pump inhibitors and ceasing oral intake during the first 3 days. At 6 months follow-up patients have no residual symptoms. ![Figure][1] X-ray and CTscan images Conclusions: Gastroparesis is a poorly defined and often under-recognized extracardiac complication caused by vagus nerve injury after CA. Delayed presentation and subtle symptoms can mask this complication. A prompt diagnosis and treatment are necessary in order to avoid significant patient morbidity [1]: pending:yes

Extracardiac Complications in Adults with Congenital Heart Disease

With the increasing number of adults living with repaired, or unrepaired, congenital heart disease, there is a growing incidence of extracardiac comorbidities. These comorbidities can affect various organ systems in complex ways, and may have a significant impact on a patient's quality of life and survival. Many of these potential complications may go undiagnosed until there is already a significant bearing on the patient's life. Therefore, it is important for physicians who care for the adult congenital patient to be mindful of these potential extracardiac complications, and actively assess for these complications in their adult congenital practice. Continued research to identify modifiable risk factors is needed so that both preventative and therapeutic management options for these extracardiac complications may be developed.

Thromboembolic risks of recombinant factor VIIa Use in warfarin-associated intracranial hemorrhage: a case–control study

BackgroundRecombinant factor VIIa (rFVIIa) may be used for rapid hemostasis in life-threatening hemorrhage. In warfarin-associated intracerebral hemorrhage (wICH), FVIIa use is controversial and may carry significant thromboembolic risks. We compared incidence of baseline thromboembolic risk factors and thromboembolism rates in wICH patients treated with additional rFVIIa to those treated with standard therapy of fresh frozen plasma (FFP) and vitamin K alone.MethodsWe identified 45 consecutive wICH patients treated with additional rFVIIa over 5-year period, and 34 consecutive wICH patients treated with standard therapy alone as comparison group. We compared the incidence of post-hemorrhage cardiac and extra-cardiac thromboembolic complications between two treatment groups, and used logistic regression to adjust for significant confounders such as baseline thromboembolic risk factors. We performed secondary analysis comparing the quantity of FFP transfused between two treatment cohorts.ResultsBoth rFVIIa-treated and standard therapy-treated wICH patients had a high prevalence of pre-existing thromboembolic diseases including atrial fibrillation (73% vs 68%), deep venous thrombosis (DVT) or pulmonary embolism (PE) (22% vs 18%), coronary artery disease (CAD) (38% vs 32%), and abnormal electrocardiogram (EKG) (78% vs 85%). Troponin elevation following wICH was prevalent in both groups (47% vs 41%). Clinically significant myocardial infarction (MI), defined as troponin > 1.0 ng/dL, occurred in 13% of rFVIIa-treated and 6% of standard therapy-treated patients (p=0.52). Past history of CAD (p=0.0061) and baseline abnormal EKG (p=0.02) were independently associated with clinically significant MI following wICH while rFVIIa use was not. The incidences of DVT/PE (2% vs 9%; p=0.18) and ischemic stroke (2% vs 0%; p=0.38) were similar between two treatment groups. Recombinant FVIIa-treated patients had lower mean INR at 3 (p=0.0001) and 6 hours (p<0.0001) and received fewer units of FFP transfusion (3 vs 5; p=0.003).ConclusionsPre-existing thromboembolic risk factors as well as post-hemorrhage troponin elevation are prevalent in wICH patients. Clinically significant MI occurs in up to 13% of wICH patients. rFVIIa use was not associated with increased incidence of clinically significant MI or other venous or arterial thromboembolic events in this wICH cohort.

Endocardites: nouveautés, pièges et controverses

Over the course of the last few decades, infective endocarditis has seen epidemiological upheaval, diagnostic and therapeutic advances. It has become an elderly person’s disease, often with no identified valve condition. It is increasingly associated with in and out-patient care. The occurrence of staphylococcal infections has doubled. Echocardiography and blood cultures remain essential diagnostic investigations. However, new microbiological tools are in the process of being evaluated. Imaging techniques (magnetic resonance imaging and positron emission tomography) frequently allow previously clinically silent septic metastases to be diagnosed. However, the impact of these diagnostic tests on treatment and in the future is yet to be determined. Surgery for left heart endocarditis is carried out in 50% of cases during the active phase and it is established that it improves the prognosis. Alongside recognised surgical procedures for severe heart failure, paravalvular extension or multiple embolisms, a recent random trial suggests that early surgical intervention in cases of valve disorders with thickening greater than 10 mm reduces the occurrence of embolic events. Neurological complications are the most common extracardiac complications. They are a frequent cause of admission to intensive care units and are given a poor prognosis. In the absence of a significant cerebral haemorrhage or ischemic lesions resulting from severe neurological impairment, surgery may be performed with a low postoperative risk of any worsening in neurological problems. Antibiotic regimens have been updated in numerous recommendations. Prophylactic antibiotics have been considerably less recommended. Endocarditis is still associated with high hospital mortality rates of between 10% and 40%.

Changing pattern of infective endocarditisin Iran: A 16 years survey

Objectives: To investigate the changes in characteristics of patients with infective endocarditis in Iran and comparing the results with the changing profiles of Infection Endocarditis (IE) in other countries. Methodology: We studied all patients with definite or possible IE seen at four referral teaching hospitals in Iran from Jan. 1995 to Dec. 2010. The data was analyzed both collectively and separately in two consecutive eight-year periods, i.e. 1995-2003 and 2004-2010. Results: A total of 286 episodes of IE, 172 males and 114 females, were reviewed from which 162 ones were in the first eight-year time period and 124 episodes in the second one. Mean age of the patients was significantly increased in the second eight-year period (24.2±11 vs 39.4±15 years old, p value = 0.01). Increase in the episodes caused by Staphylococcus aureus was significant (40.7% vs 22.8%, p value = 0.01). The mean size of the vegetation was noticeably higher among IDUs than non-IDUs (1.53±0.1cm vs 0.76±0.2cm, p value < 0.001). As well as extra cardiac complications, mortality rate was noticeably higher among the patients with vegetation size ≥ 1cm (34.4% vs 16.3%, p value = 0.003). There was not a significant difference regarding the mortality rate between the conservatively and surgically treated patients (20.7% vs 22.9%, p value = 0.07). Conclusion: The most important changing characteristic of IE which influences the outcome of the disease seems to be vegetation size which can account for as the outcome predictor.

Italian patent foramen ovale survey (I.P.O.S.): Early results

Summary Background Percutaneous patent foramen ovale (PFO) closure is gaining wide acceptance. Aims of the study were to analyse clinical practice regarding PFO closure in Italy, to study indications, devices, results, and the follow-up of large series of patients treated by percutaneous PFO closure. Methods and patients Italian patent foramen ovale survey (IPOS) is a prospective, observational, multi-centric survey that uses a web-based database. The survey lasted 12 months, (November 2007–October 2008). 50 centres participated. Ongoing follow-up will continue up to 36 months. 1035 patients (m.a. 46 years, 60% females) were included in the registry. Most subjects were treated due to a previous history of TIA/ischemic stroke (∼80% of patients). PFO diagnosis and right-to-left shunt (RLS) were assessed by contrast-enhanced transesophageal (cTEE) and/or transthoracic echocardiography and/or transcranial doppler. An aneurysm of the interatrial septum was associated in 41% of patients. Intraprocedural monitoring was assessed by using cTEE and fluoroscopy in 70% and intracardiac echocardiography in 30% of subjects. Procedures were performed under general anesthesia and local anesthesia/conscious sedation in 54% and 46% of patients respectively. The most used device for PFO closure was Amplatzer (∼70% of cases). Results The procedure was successful in all patients. Early complications occurred in 24/1035 patients (2.3%): 12/24 (50%) of them had cardiac arrhythmias, 1 subject had a TIA. Data regarding both clinical and cardio-neurosonological follow-up were assessed in 444/1035 (43%) subjects. The rate of neurological events and cardiac and extra-cardiac complications were around 3% and 9% up to the 24-month follow-up respectively. A large permanent residual RLS and no RLS were observed in less than 1% and in ∼82% of patients at the 1-year follow-up, respectively. Conclusions Our data confirm that percutaneous PFO closure is a safe procedure. Early complications and those during follow-up are mostly related to arrhythmias. Longer follow-up is under way.

Respective effects of early cerebral and abdominal magnetic resonance imaging on clinical decisions in infective endocarditis

Extracardiac complications of endocarditis influence diagnosis, therapeutic plans, and prognosis. The aim of this study was to assess how early combined cerebral and abdominal magnetic resonance imaging (MRI) affects the diagnosis and management of adults with endocarditis. In a single-centre prospective study, 58 patients with endocarditis underwent systematic cerebral and abdominal MRI within 7 days following admission. Diagnostic classification (Duke's modified criteria) and therapeutic plans were established by two experts just before and after MRI and then compared. Endocarditis was initially classified as definite in 29 patients, possible in 27, and excluded in 2. MRI detected cerebral lesions in 47 patients (81%) (ischaemic lesions in 25, microbleeds in 32, and silent aneurysms in 6), and abdominal lesions in 20 patients (34%). Based solely on MRI results without taking microbleeds into account, experts upgraded endocarditis diagnostic classification in 8 out of 29 (28%) non-definite endocarditis cases either to definite in 6 or to possible in 2. This upgrading was exclusively due to cerebral MRI in four patients and to cerebral and/or abdominal MRI in four patients. Experts modified endocarditis therapeutic plans in 11 (19%) out of the 58 patients, based solely on cerebral MRI, including modification of surgical plans in six (10%) patients. Overall, early MRI led experts to modify classification and/or therapeutic plans in 16 (28%) patients. MRI identified cerebral and/or abdominal asymptomatic lesions in many patients with endocarditis, but more frequently cerebral. Both cerebral and abdominal MRI findings affected diagnosis, but only cerebral MRI affected clinical management plans. CLINICALTRIALS.GOV IDENTIFICATION NUMBER: NCT 00144885. IRB AUTHORIZATION NUMBER: 0511114 (Comité Protection des Personnes Paris-Ile de France 1).

ST‐Elevation myocardial infarction as a complication of retrograde chronic total occlusion recanalization

With the advent of new tools and techniques including the retrograde approach, success rates for recanalization of chronic total occlusion (CTO) have improved. Numerous cardiac and extracardiac complications during retrograde CTO recanalization have been described. To date the development of ST-segment elevation myocardial infarction (STEMI) with retrograde recanalization as a result of atheroembolization has not been reported. We report such a case following retrograde recanalization of a totally occluded right coronary artery.

Septic pulmonary embolisms and metastatic infections from methicillin-resistant Staphylococcus aureus endocarditis on FDG PET/CT

A 59-year-old immune-compromised woman after nonmyeloablative allogeneic stem cell transplantation for myelodysplastic syndrome, was admitted with methicillinresistant Staphylococcus aureus sepsis related to a Hickman catheter. Despite aggressive antibiotic therapy and catheter removal, blood cultures remained positive and her dyspnoea continued unabated. Subsequent transoesophageal/transthoracic echocardiography demonstrated infective endocarditis with a focal vegetation (10× 4 mm) on the posterior leaflet, a perforation in the 2-3 section of the posterior leaflet and severe mitral regurgitation (4/4). She was then referred for a PET/CT scan with F-FDG to rule out septic embolism and metastatic infection. The coronal maximum intensity projection image (a) revealed focally increased uptake in the left ventricle (dashed arrow). In addition, numerous hypermetabolic small nodules were scattered throughout both lungs, and hypercaptation was seen around the left hip and right shoulder (arrows). PET, CT and fused PET/CT images localized the increased myocardial uptake to the mitral valve (b) and pulmonary FDG uptake projected onto multiple parenchymal nodules, some with central excavation (c). The periarticular uptake corresponded to septic arthritis of the acromioclavicular joint extending into the supraspinatus tendon and a collection within the quadratus femoris muscle (d). These imaging findings are characteristic of infective endocarditis with septic pulmonary embolisms and metastatic muscle abscesses and septic arthritis. Acute infective endocarditis is a potentially life-threatening disease with an outcome that depends on the presence of systemic embolization and extracardiac infections. This case illustrates the power and value of PET/CT in assessing extracardiac complications. O. Gheysens (*) :N. Lips : L. Mortelmans Department of Nuclear Medicine, University Hospital Leuven, Leuven, Belgium e-mail: olivier.gheysens@uzleuven.be

Extracardiac complications of the Fontan circuit

The Fontan operation is the primary surgical procedure used in the palliation of patients with univentricular cardiac physiology. With improved survival of children with congenital heart disease, long-term complications of the Fontan circuit are being encountered more frequently. Radiologists are more likely to see both the cardiac and extracardiac complications of the Fontan circuit. Awareness of the common extracardiac complications in children with failing Fontan circuits will aid the radiologist in making the appropriate diagnosis and guide the cardiologist caring for these patients.

Atrial Remodeling and Novel Pharmacological Strategies for Antiarrhythmic Therapy in Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. It can occur at any age, however, it becomes extremely common in the elderly, with a prevalence approaching more than 20% in patients older than 85 years. AF is associated with a wide range of cardiac and extra-cardiac complications and thereby contributes significantly to morbidity and mortality. Present therapeutic approaches to AF have major limitations, which have inspired substantial efforts to improve our understanding of the mechanisms underlying AF, with the premise that improved knowledge will lead to innovative and improved therapeutic approaches. Our understanding of AF pathophysiology has advanced significantly over the past 10 to 15 years through an increased awareness of the role of "atrial remodeling". Any persistent change in atrial structure or function constitutes atrial remodeling. Both rapid ectopic firing and reentry can maintain AF. Atrial remodeling has the potential to increase the likelihood of ectopic or reentrant activity through a multitude of potential mechanisms. The present paper reviews the main novel results on atrial tachycardia-induced electrical, structural and contractile remodeling focusing on the underlying pathophysiological and molecular basis of their occurrence. Special attention is paid to novel strategies and targets with therapeutic significance for atrial fibrillation.

Infective endocarditis in congenital heart disease

Congenital heart disease (CHD) has become the leading risk factor for pediatric infective endocarditis (IE) in developed countries after the decline of rheumatic heart disease. Advances in catheter- and surgery-based cardiac interventions have rendered almost all types of CHD amenable to complete correction or at least palliation. Patient survival has increased, and a new patient population, referred to as adult CHD (ACHD) patients, has emerged. Implanted prosthetic material paves the way for cardiovascular device-related infections, but studies on the management of CHD-associated IE in the era of cardiovascular devices are scarce. The types of heart malformation (unrepaired, repaired, palliated) substantially differ in their lifetime risks for IE. Streptococci and staphylococci are the predominant pathogens. Right-sided IE is more frequently seen in patients with CHD. Relevant comorbidity caused by cardiac and extracardiac episode-related complications is high. Transesophageal echocardiography is recommended for more precise visualization of vegetations, especially in complex type of CHD in ACHD patients. Antimicrobial therapy and surgical management of IE remain challenging, but outcome of CHD-associated IE from the neonate to the adult is better than in other forms of IE. Primary prevention of IE is vital and includes good dental health and skin hygiene; antibiotic prophylaxis is indicated only in high-risk patients undergoing oral mucosal procedures.

Cardiac and extracardiac complications during CTO interventions: prevention and management

Percutaneous coronary intervention of chronic total occlusion carries the risk of severe complications that are responsible for a significant morbidity and mortality rate associated with these procedures. Complications may be cardiac, such as acute myocardial infarction and coronary perforation, or extracardiac, such as aortic dissection, contrast-induced nephropathy and radiation skin injuries. The mechanisms, prevention and treatment of complications associated with percutaneous coronary intervention of chronic total occlusion are reviewed in this article.

Surgery for Infective Endocarditis

Infective endocarditis (IE) remains a dangerous condition with unchanging incidence and a mortality approaching 30% at 1 year.1,2 Surgery is potentially lifesaving3 and is required in 25% to 50% of cases during acute infection and 20% to 40% during convalescence.4–7 Operative procedures are often technically difficult and associated with high risk, not least because patients are frequently extremely sick with multisystem disease. Nevertheless, indications for surgery are clear in many patients, and international guidelines8,9 provide strong recommendations that are applicable for the majority. These guidelines are not supported by robust clinical evidence, however, and clinical decision making is often hampered by diverse considerations, including advancing age of the overall patient cohort, the presence of extracardiac complications or preexistent comorbidity, prior antibiotic therapy of varying duration, and the availability of appropriate surgical expertise. In this article, we review the evidence base that supports current clinical practice and attempt to provide recommendations in areas where doubt persists. The role of surgery in active IE has expanded progressively since early reports of successful outcome.10 Subsequent declines in mortality may be attributed to a variety of improvements in management, although expeditious surgery in carefully selected patients has played a major role. Contemporary data in Europe indicate that surgery is now undertaken in approximately 50% of patients with IE; the most frequent indications are congestive heart failure (60%), refractory sepsis (40%), embolic complications (18%), and vegetation size (48%), with a combination of these factors being present in many patients.11 Overall surgical mortality in active IE is 6% to 25%, with long-term survival rates of approximately 70% in most series.4–7,12–31 Assessment of the impact of surgery on outcome is difficult, because the patients referred are frequently those with severe complications related to virulent organisms. Conversely, the most ill patients …

Endocarditis Caused by Staphylococcus aureus

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.

Subclinical atherosclerosis after heart and heart–lung transplantation in childhood

Children after heart transplantation are considered as at-risk patients for extracardiac atherosclerotic complications. Noninvasive ultrasound measurement of the common carotid artery (IMT) provides valid information about the endothelial structure of the vascular system. Twenty-two patients (17 male, mean age 12.4 +/- 4.5 yr) after heart and (5.7 +/- 4.5 yr) heart-lung transplantation were enrolled. The mean IMT was measured and compared with a control group (18 children, 10 male, mean age 11.8 +/- 1.8 yr) and to normative data. Transplanted children had a higher IMT than controls (0.453 +/- 0.003 vs. 0.424 +/- 0.002 mm, p < 0.001). IMT-SDS was increased as well (1.6 +/- 0.1 vs. 0.8 +/- 0, p < 0.001). Transplanted children had a higher LDL/HDL-ratio (2.2 +/- 0.2 vs. 1.2 +/- 0.1, p < 0.001). Time after transplantation, age at the time of transplantation, or medical therapy did not influence the findings. We found evidence for subclinical atherosclerosis in children after heart and heart-lung transplantation. Even if single atherosclerotic risk factors could not be identified, transplanted children seem to be at risk for atherosclerosis. Our findings support the recently published statement of the AHA-Expert panel: after heart transplantation atherosclerotic complications may occur with increased incidence. We propose the IMT-measurement in these patients as an easy method to assess the vascular status and to guide preventive measures.

Radiologic manifestations of extra-cardiac complications of infective endocarditis

Infective endocarditis (IE) is a disease with high morbidity and a mortality rate of 9-30%, even with appropriate diagnosis and therapy. Septic emboli, caused by IE, can affect any organ or tissue in the body with an arterial supply and occur in 12-40% of IE cases. The most common extra-cardiac organ system involved in IE is the central nervous system. Other organs frequently involved are the lungs (especially in right-sided IE), spleen, kidneys, liver, and the musculoskeletal system. In addition, the arterial system itself is susceptible to the development of potentially fatal mycotic aneurysms. As extra-cardiac complications often antedate the clinical diagnosis of IE, it is important that the diagnosis is suggested when characteristic findings are encountered during imaging. In addition, imaging is often used to monitor the extent of complications in patients with a known diagnosis of IE.

Arterial Switch Operation with Ventricular Septal Defect Repair and Aortic Arch Reconstruction

The arterial switch operation for transposition of the great arteries or double outlet right ventricle with ventricular septal defect (VSD) and aortic arch obstruction is a challenging procedure. One-stage neonatal repair is preferred; however, palliation may be indicated in the newborn who presents with Swiss cheese septum or the patient with extracardiac complications such as necrotizing enterocolitis or subarachnoid hemorrhage. The aortic arch repair is performed with continuous cerebral perfusion and includes patch enlargement of the transverse aortic arch and ascending aorta to control for the important diameter mismatch between the aorta and the pulmonary root. The VSD is no longer closed through the pulmonary valve. Instead, the VSD is approached through the aortic valve after harvesting of the coronary buttons and/or through the tricuspid valve and, if necessary, through an infundibulotomy. The coronary artery transfer is often complex because of the presence of unusual coronary artery patterns and requires precise technique. Subaortic obstruction is often present and requires correction. The right ventricle can be mildly hypoplastic but is not a contraindication to repair unless there is important tricuspid stenosis.

Ascites and Other Extracardiac Manifestations Associated with Right Atrial Myxoma

Right atrial myxomas are rare intracardiac tumors that often pose difficulties in diagnosis. Right ventricular failure and ascites ensuing from tricuspid valve orifice obstruction are potentially dangerous complications. Early diagnosis of cardiac myxoma is important since surgical treatment leads to disappearance of all symptoms with a low rate of recurrence and good long-term survival. Nonspecific extracardiac symptoms, signs, complications, and laboratory findings may be the initial manifestations contributing to misdiagnosis of these rare but totally treatable atrial tumors.