Indication For Valve Surgery Research Articles

Clinical Management and Pathophysiology of Infective Endocarditis: An Updated Review of Diagnostic Challenges and Therapeutic Approaches

Infective endocarditis (IE) is a severe and life-threatening condition characterized by infection of the endocardial surface of the heart, primarily affecting the heart valves. Despite advances in diagnostic techniques and antimicrobial therapies, IE remains associated with significant morbidity and mortality due to its complex pathogenesis and clinical variability. This article reviews the most recent developments in the pathophysiology, diagnostic criteria, and management strategies of infective endocarditis. Key issues such as microbial etiology, including common pathogens like Staphylococcus aureus and Streptococcus species, are discussed alongside less frequent organisms and their association with specific patient populations. The article emphasizes the importance of early diagnosis using advanced imaging modalities, such as echocardiography and PET-CT, and laboratory findings, particularly blood cultures. We explore both medical and surgical management strategies, highlighting the role of antibiotic therapy and the indications for valve surgery. A focus is given to the management of complex cases, including prosthetic valve endocarditis and infections in immunocompromised patients. The article aims to provide clinicians with a comprehensive understanding of the evolving landscape of infective endocarditis and its implications for patient outcomes.

Comparison of Medical Therapy, Valve Surgery, and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis

BackgroundThe opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided infective endocarditis are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients at high risk for re-infection of a prosthetic valve but lacks robust outcomes data.This retrospective analysis compares the primary outcome of death within 1 year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy alone vs percutaneous mechanical aspiration or valve surgery. MethodsThe authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic-and outcomes-related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting. ResultsBetween January 1, 2009, and December 31, 2018, 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the 3 treatment groups (P = .15). Vegetation size > 2.0 cm was associated with increased 1-year mortality (hazard ratio 3.01; P = .03). Addiction medicine consultation was associated with decreased 1-year mortality (hazard ratio 0.117; P = .0008). ConclusionThe study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated tricuspid valve infective endocarditis. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.

Evolution of Infective Endocarditis Profiles in South-Central Chile: A Four-Decade Analysis of Surgical Patients

To describe the changes observed in operated patients with infective endocarditis (IE) in the south-central region of Chile during the last four decades. Case series study. The target population was patients diagnosed with IE and indication for valve surgery between 1983 and 2020 from a Chilean public hospital. The universe (n = 306) was divided into four groups according to the period of valve surgery. Sociodemographic and clinical variables between these groups were compared using the Kruskal-Wallis and Chi-square tests for independence. Cumulative survivals were calculated and compared using the Gehan-Breslow-Wilcoxon test. Age at diagnosis (p < 0.001), frequency of comorbidities (p < 0.001), clinical presentation compatible with acute kidney injury (p < 0.001), independent mitral valve involvement (p < 0.001), positivity of microbiological cultures (p < 0.012) and cumulative survival (p = 0,015) increased. The delay from symptom onset to diagnosis (p = 0.003), clinical presentation compatible with heart failure (p < 0.001), independent involvement of the aortic valve (p < 0.001), and surgical indication for large vegetation (p < 0.001) decreased. The IE profile of patients seen in a public hospital in the south-central region of Chile has undergone significant changes during the last four decades.

Tricuspid regurgitation management: a systematic review of clinical practice guidelines and recommendations.

Tricuspid regurgitation (TR) is a highly prevalent condition and an independent risk factor for adverse outcomes. Multiple clinical guidelines exist for the diagnosis and management of TR, but the recommendations may sometimes vary. We systematically reviewed high-quality guidelines with a specific focus on areas of agreement, disagreement, and gaps in evidence. We searched MEDLINE and EMBASE (1 January 2011 to 30 August 2021), the Guidelines International Network International, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed (as assessed by the Appraisal of Guidelines for Research and Evaluation II tool). Three guidelines were finally retained. There was consensus on a TR grading system, recognition of isolated functional TR associated with atrial fibrillation, and indications for valve surgery in symptomatic vs. asymptomatic patients, primary vs. secondary TR, and isolated TR forms. Discrepancies exist in the role of biomarkers, complementary multimodality imaging, exercise echocardiography, and cardiopulmonary exercise testing for risk stratification and clinical decision-making of progressive TR and asymptomatic severe TR, management of atrial functional TR, and choice of transcatheter tricuspid valve intervention (TTVI). Risk-based thresholds for quantitative TR grading, robust risk score models for TR surgery, surveillance intervals, population-based screening programmes, TTVI indications, and consensus on endpoint definitions are lacking.

Valve phenotype and likelihood of surgery in patients with bicuspid aortic valve

Abstract Background It is well established, that patients with bicuspid aortic valve (BAV) are at increased risk of developing severe aortic valve and/or aortic disease early in life. Knowledge of factors placing patients at risk of early surgery is therefore essential. Several studies have found associations between aortic valve phenotype, aortopaty and type of valve dysfunction. Purpose To characterize the valve phenotype associated with increased likelihood of early surgery of the aortic valve and aorta in a large cohort of BAV patients. Methods A retrospective study of adult BAV patients seen in the outpatient clinics at two hospitals in Denmark from 2006 until May 2020. Clinical and anatomical data were obtained retrospectively from electronic health charts and hospital echocardiography databases. Bicuspid valve morphology was classified according to Sievers Classification; no raphe (Type 0), one raphe (Type 1 with fusion of the right-noncoronary cusps (R/N), Left-noncoronary cusp fusion (L/N) and Left-right coronary cusp fusion (L/R)) or 2 raphes (Type 2). Likelihood of surgery was calculated using odds ratio (OR). We performed multivariate regression models to adjust for potential confounding by sex, age, coarctatio aorta, aortic dilatation and cardiovascular risk factors. Results A total 983 BAV patients were identified of whom 877 had an available baseline echocardiography and were included. Clinical and echocardiographic characteristics are seen in Table 1. Noteworthy is that Type 2 patients had significantly higher occurrence of moderate-severe aortic regurgitation when compared to the whole population (38.9% vs 18.3%, p&amp;lt;0.01). During the study period 305 patients (34.8%) underwent surgery. Median age at time of surgery was 62 (IQR 55; 69) years. Using the most common phenotype (Type 1 L/R fusion) as a reference, patients with Type 0 had a lower likelihood of surgery (unadjusted OR 0.58, 95% CI: 0.39–0.85), while patients with Type 2 had a significantly higher likelihood of surgery (OR 2.76, 95% CI: 1.05–7.23). In a multiple regression analysis, adjusting for age, sex, coarctatio aorta and aortic dilatation did not change the primary finding of association between BAV phenotype and OR for surgery. Likelihood of surgery was lower for women (OR 0.66, 95% CI: 0.46–0.96) and increased with age. Further adjustments for cardiovascular risk factors (mentioned in Table 1) did not change the results. Median age at time of surgery was younger for patients with Type 2 (59 years, IQR 44; 65). Indications for valve surgery are shown in Table 2. Conclusion In this study we found significant association between valve phenotype and likelihood of surgery of the valve or aorta in patients with bicuspid aortic valve. Using BAV Type 1 L/R as reference, likelihood of surgery was lower in patients with BAV type 0, and higher in patients with BAV type 2. Results were consistent after adjustment for confounders in multivariate analyses. Funding Acknowledgement Type of funding sources: None.

Cerebrovascular Complication and Valve Surgery in Infective Endocarditis.

Infective endocarditis (IE) with neurologic complications is common in patients with active IE. The most common and feared neurological complication of left-sided IE is cerebrovascular, from septic emboli causing ischemic stroke, intracranial hemorrhage (ICH), or an infectious intracranial aneurysm with or without rupture. In patients with cerebrovascular complications, valve replacement surgery is often delayed for concern of further neurological worsening. However, in circumstances when an indication for valve surgery to treat IE is present, the benefits of early surgical treatment may outweigh the potential neurologic deterioration. Furthermore, valve surgery has been associated with lower in-hospital mortality than medical therapy with intravenous antibiotics alone. Early valve surgery can be performed within 7 days of transient ischemic attack or asymptomatic stroke when medically indicated. Timing of valve surgery for IE after symptomatic medium or large symptomatic ischemic stroke or ICH remains challenging, and current data in the literature are conflicting about the risks and benefits. A delay of 2 to 4 weeks from the time of the cerebrovascular event is often recommended, balancing the risks and benefits of surgery. The range of timing of valve surgery varies depending on the clinical scenario, and is best determined by a multidisciplinary decision between cardiothoracic surgeons, cardiologists, infectious disease experts, and vascular neurologists in an experienced referral center.

Midterm results after St Jude Medical Epic porcine xenograft for aortic, mitral, and double valve replacement.

The aim of this study was to evaluate the results after stented porcine xenograft implantation (Epic, SJM, St Paul, MN) with Linx anticalcification treatment in elderly patients at our high-volume tertiary care center. A total of 3825 patients undergoing aortic (AVR = 2441), mitral (MVR = 892), or double valve (DVR = 492) replacement between 11/2001 and 12/2017 with Epic xenografts were evaluated. Outcomes were assessed by reviewing the prospectively acquired hospital database results, and regular annual follow-up information was acquired from questionnaires or telephone interviews. For patients undergoing AVR, MVR, DVR, age at surgery were 76.4 ± 6, 71.2 ± 9, 72.9 ± 8 years; active endocarditis was an indication for valve surgery in 4.5%, 20.7%, 19.7%; and the predicted median (interquartile range [IQR]) mortality risk (EuroSCORE II) was 5.2% (3.1%-9.4%), 7.5% (3.9%-16.2%), 9.9% (6.0%-19.6%), respectively. Median follow-up was 3.04 (IQR: 0.18-5.21). Thirty-day survival was 91.2% ± 0.6%, 87.6% ± 0.1.1%, 84.7% ± 1.6%; and 10-year survival was 56.7% ± 1.0%, 59.4% ± 2.5%, 50.45% ± 3.1%, respectively. Patients who underwent MVR versus AVR were at significant increased risk for reoperation for endocarditis (adjusted odds ratio; 2.2, 95% confidence interval; 1.29-3.7; P = .003). There was no significant difference in all-cause mortality at midterm in AVR vsMVR in the matched cohort (P = .85). Implantation of the Epic stented porcine xenograft is associated with acceptable survival and freedom from valve-related complications or reoperation due to structural valve disease at midterm follow-up.

P3628Contemporary coronary artery disease prevalence in a valvular heart disease population undergoing surgery

Abstract Background Patients undergoing heart valve surgery are routinely evaluated for the presence of Coronary Artery Disease (CAD), with the standard practice of combining valve intervention with a revascularization procedure, notably Coronary Artery Bypass Graft (CABG). Older studies suggest rates as high as 50% prevalence of CAD in this population. However, CAD prevalence, its treatment and prognostic implication has been questioned recently. Objectives The goal of this study is to evaluate the baseline characteristics, prevalence of CAD and treatment strategies in a contemporary population with valvular heart disease (VHD) referred for valve surgery. Methods In a national multicentre registry, consecutive patients, from Jan 2015 to Dec 2016, with a formal indication for heart valve surgery referred for a pre-op routine coronary angiogram were systematically analysed. Baseline characteristics, valve pathology and CAD prevalence and patterns were determined. Obstructive CAD was defined as luminal angiographic stenosis ≥70% (≥50% for left main artery). The prognostic impact of the different valve disease and CAD treatment strategies were assessed. Results 1175 patients (mean age 72.5±10.1; male 49.2%) fulfilled the clinical or echocardiographic indication for valve surgery by European guidelines. Valvular disease prevalence was: aortic stenosis (66.7%), aortic regurgitation (6.6%), mitral stenosis (6%), mitral regurgitation (19.2%), tricuspid regurgitation (7.5%). Mean follow-up time was 29.06±18.46 months. Prevalence of comorbidities was: Diabetes Mellitus (DM) 26%, chronic obstructive pulmonary disease (COPD) 5.7% and chronic kidney disease (CKD) 23.4%. Mean Euroscore II was 2.6%. Obstructive CAD was present in 27.3% patients. Mean Syntax score was 10.2 (&lt;22 in 88%, 23–32 in 10.2% and &gt;33 in 1.8%). Left main artery and 3-vessel disease were found in 13.1% and 11.8% of patients with CAD, respectively. Valvular surgery was ultimately performed in 80.3%. In patients with CAD, 57.3% were revascularized. All-cause mortality rate during follow-up was 12.9%, with 7.8% from cardiovascular causes. In univariate analysis DM, COPD, CKD, NYHA class, obstructive CAD and no surgery (p&lt;0.05) were associate with mortality on follow up. In multivariate analysis obstructive CAD (OR 2.36, 95% CI 1.53–3.65, p&lt;0.01) and no surgery (OR 6.05, 95% CI 3.95–9.30, p&lt;0.01) persisted as independent all-cause mortality predictors. Conclusion In a contemporary cohort of patients with VHD and surgical indication, CAD prevalence is lower (27.3%) than described in literature. Mortality rates were higher in patients with obstructive CAD, worse NYHA functional class and in those who never underwent surgery.

Prevalence and characteristics of primary left-sided valve disease in a cohort of 15,000 patients undergoing echocardiography studies in a tertiary hospital in Uganda

BackgroundAlthough rheumatic heart disease remains the leading cause of valve heart disease (VHD) in developing countries, other forms of valve disease have been over shadowed and not regarded as a public health problem. However, several facts suggest that the role of non-rheumatic VHD as a significant cardiovascular disease should be reconsidered. We aimed to assess the prevalence and characteristics of different forms of primary left sided valve diseases from a series of 15,009 echocardiographic studies.MethodsThis was a retrospective review of echocardiographic reports for studies performed between January 2012 and December 2013 (24 months) at Uganda Heart Institute. All patients with primary left-sided valve disease were classified into one of five major diagnostic categories and in each diagnostic category; patients were sub-classified into stages A-D of primary valve disease as defined by the American College of Cardiology.ResultsThree thousand five hundred eighty-two echocardiography reports qualified for final data analysis. The “sclerotic valve changes with normal valve function”, a Stage A sub-class of “degenerative valve disease” overwhelmingly overshadowed all the other diagnostic categories in this stage. “Rheumatic Heart Disease”, “Degenerative Valve Disease”, “Bicuspid Aortic Valve”, “Mitral Valve Prolapse” and “Endomyocardial Fibrosis” diagnostic categories accounted for 53.0%, 41.8%, 2.2%, 1.4% and 1.7% respectively in stages B-D of primary VHD. Rheumatic heart disease disproportionately affected the young, productive age groups. It was the major risk factor for infective endocarditis; and was the indication for valve surgery in 44 of 50 patients who had undergone valve replacement procedures.ConclusionsWe acknowledge that rheumatic heart disease remains a leading cause of progressive and severe primary left-sided valve disease among young adults in Uganda. But we bring to light the contemporary footprints of other forms of primary valve disease that require coordinated multidisciplinary approach to research, education and clinical management to ensure improved patient outcomes.

Symptomatic and Asymptomatic Neurological Complications of Infective Endocarditis: Impact on Surgical Management and Prognosis.

ObjectivesSymptomatic neurological complications (NC) are a major cause of mortality in infective endocarditis (IE) but the impact of asymptomatic complications is unknown. We aimed to assess the impact of asymptomatic NC (AsNC) on the management and prognosis of IE.MethodsFrom the database of cases collected for a population-based study on IE, we selected 283 patients with definite left-sided IE who had undergone at least one neuroimaging procedure (cerebral CT scan and/or MRI) performed as part of initial evaluation.ResultsAmong those 283 patients, 100 had symptomatic neurological complications (SNC) prior to the investigation, 35 had an asymptomatic neurological complications (AsNC), and 148 had a normal cerebral imaging (NoNC). The rate of valve surgery was 43% in the 100 patients with SNC, 77% in the 35 with AsNC, and 54% in the 148 with NoNC (p<0.001). In-hospital mortality was 42% in patients with SNC, 8.6% in patients with AsNC, and 16.9% in patients with NoNC (p<0.001). Among the 135 patients with NC, 95 had an indication for valve surgery (71%), which was performed in 70 of them (mortality 20%) and not performed in 25 (mortality 68%). In a multivariate adjusted analysis of the 135 patients with NC, age, renal failure, septic shock, and IE caused by S. aureus were independently associated with in-hospital and 1-year mortality. In addition SNC was an independent predictor of 1-year mortality.ConclusionsThe presence of NC was associated with a poorer prognosis when symptomatic. Patients with AsNC had the highest rate of valve surgery and the lowest mortality rate, which suggests a protective role of surgery guided by systematic neuroimaging results.

Porcine xenograft for aortic, mitral and double valve replacement: long-term results of 2544 consecutive patients.

The aim of this study was to evaluate the results after stented porcine xenograft implantation with Linx™ anticalcification treatment in the aortic and/or mitral position in elderly patients. Over a decade, a total of 2544 patients receiving aortic (AVR = 1920), mitral (MVR = 347) or double valve (DVR = 277) replacement (between November 2001 and March 2012) were evaluated. The study was designed on an 'all comers' basis including all patients with elective, urgent or emergent need for valve replacement. Outcome was assessed by reviewing the prospectively acquired hospital database as well as regular follow-up information obtained by annual written interviews. Mean patient age was 76.5 ± 6 (AVR), 73.8 ± 7 (MVR) and 74.2 ± 7 (DVR) years, respectively; 54.2%/41.9%/42.0% were male, and active endocarditis was diagnosed in 4.5%/19.9%/22.1%; indication for valve surgery and the logistic EUROSCORE I predicted risk for mortality was 15.4 ± 15%/19.9 ± 19%/22.3 ± 21%, respectively. Concomitant mitral valve repair was required in 196 (10.2%) (AVR) patients; coronary artery bypass graft surgery (CABG) in 840 (43.8%) (AVR), 82 (23.7%) (MVR) and 94 (34.1%) (DVR) patients; cryoablation in 232 (12.1%)/81 (23.4%)/67 (24.3%) patients and surgery on the thoracic aorta in 166 (8.7%)/12 (3.5%)/41 (14.9%) patients, respectively. The mean follow-up was 4.5 ± 3.5 years. The rate of freedom from endocarditis after 10 years was 98.3 ± 0.4%/97.5 ± 1.0%/97.4 ± 1.6% (P = n.s.). The rate of freedom from structural valve disease was 96.3 ± 0.6%/93.8 ± 2.4%/92.8 ± 2.2% (AVR versus DVR, P = 0.009), and from thromboembolic events was 94.8 ± 1.0%/91.5 ± 2.9%/97.9 ± 1.3%. The 30-day survival rate was 97.3 ± 0.4%/95.1 ± .1.2%/92.8 ± 1.6% and the 10-year survival rate was 42.1 ± 1.5%/33.9 ± 4.7%/22.1 ± 7.1%, respectively. The Epic™ stented porcine xenograft is associated with acceptable survival, with large proportions of patients free from valve-related complications and freedom from valve reintervention for all older, in-coming patients.

Abstract 17193: Porcine Xenograft for Aortic-, Mitral- and Double Valve Replacement. Longterm Results

Introduction: Aim of this study was to evaluate the results after stented porcine xenograft implantation (EpicTM, SJM, St.Paul, MN, USA) with Linx™ anticalcification treatment in elderly patients. Methods: A total of 2544 patients receiving aortic (AVR = 1920), mitral (MVR = 347) or double valve (DVR = 277) replacement between 11/2001 and 03/2012 were evaluated. All Patients having elective or emergency indications were included. Outcome was assessed by reviewing the prospectively acquired hospital database results as well as regular follow-up information by annual written interview. Results: Patient age was 76.5±6 (AVR), 73.8±7 (MVR) and 74.2±7 (DVR) years; 54.2% / 41.9% / 42.0% were male, active endocarditis was in 4.5% / 19.9% / 22.1% indication for valve surgery and the logistic EUROSCORE predicted risk for mortality was 15.4±15% / 19.9±19% / 22.3±21%, respectively. Additional surgical procedures were mitral valve repair in 196 (10.2%) (AVR) patients, CABG in 840 [43.8%] (AVR), 82 [23.7] (MVR) and 94 [34.1%] (DVR) patients, cryoablation in 232 [12.1%] / 81 [23.4%] / 67 [24.3%] patients, and surgery on the thoracic aorta in 166 [8.7%] / 12 [3.5%] / 41 [14.9%] patients. Mean aortic cross clamp time was 72.6±28min / 79.9±41min / 125.3±44min. Mean follow-up was 4.2±3.3 years. Freedom from endocarditis after 9 year was 98.3±0.4% / 97.5±1.0% / 97.4±1.6% (p=n.s.). Freedom for valve reoperation was 96.3±0.6% / 93.8±2.4% / 92.8±2.2% (AVR vs. DVR p=0.009). Freedom from neurological event was 95.4±0.9 / 91.5±2.9 / 97.9±1.3. 30 day survival was 89.1±0.07% / 80.4±.2.1% / 77.5±2.5% and 9 year survival was 44.0±1.3% / 33.9±4.7% / 29.5±4.1%, respectively. Conclusions: EpicTM stented porcine xenograft is associated with acceptable survival, freedom from valve related complication and freedom from valve reintervention.

Abstract 11763: Impact of Beta Blockade on Prognosis in Patients With Chronic Severe Degenerative Mitral Regurgitation

Background: The impact of chronic beta blockade (BB) on cardiac events (CE) in patients (pts) with chronic severe mitral regurgitation (MR) has not been studied by randomized trials but is inferred as beneficial from observational data. However a recent randomized preclinical study demonstrated increased mortality with BB in MR. Methods: We retrospectively analyzed 45 consecutive study-eligible pts (age 49±12 yrs, 69% male) with isolated chronic severe non-ischemic MR without concomitant coronary disease, followed through 19 yrs, to assess impact of chronic BB use at entry on CE (death or indications for valve surgery). At entry, all pts were non-hypertensive (HTN) and free of surgical indications; 9 pts chronically received BB at entry (of whom 7 continued receiving BB throughout the study period). CE rate differences were assessed by Kaplan-Meier log rank comparison; 6 pts on non-selective BBs were analyzed separately on an exploratory basis. Cox model analysis was used to adjust for variations in other baseline covariates (age, gender, etiology, other cardiac drugs). Results: During follow-up, CE included: sudden death (1), heart failure (8), a-fib (6), left ventricular (LV) dimensions (IDs)&gt;4.5cm (11), LV ejection fraction (EF)&lt;60% (6), right ventricular (RV) EF&lt;35% (2), combination CE (7). CE risk was 2-fold higher among pts receiving BB (Avg annual risk [AAR]= 15.28%) vs. those not receiving BB (AAR= 33.04%) (p&lt;.05) (Figure). A &gt; 3-fold relative CE risk was observed when pts on selective BB were excluded (AAR: BB vs no BB = 56.18% vs. 15.28%, p=.01). BB effects remained statistically significant (p&lt;.05) when analyses were adjusted for other baseline covariates. Conclusions: Contrary to earlier observational data, in our series BB appears to increase CE risk in pts without HTN. Further research including larger numbers of MR pts, preferably via randomized design, is needed to clarify the discrepancy between the different findings among existing studies.

Relation of Indirect Vasodilator Use to Prognosis in Patients with Chronic Severe Mitral Regurgitation

Objectives: The relation of indirect vasodilator use to cardiac events (CE) is undefined for chronic severe nonischemic mitral regurgitation (MR). The aim of this study was to resolve this knowledge deficiency. Methods: Data from 52 consecutive patients in our prospective natural history study with isolated chronic severe nonischemic MR were assessed post hoc over 19 years to examine the relation of indirect vasodilator use to subsequent CE (death or indications for valve surgery). At entry, no patient had surgical indications, 14% had hypertension (HTN) and 7 chronically received vasodilators (5 angiotensin-converting enzyme inhibitor, 1 receptor blocker and 1 α-adrenergic blocker). CE differences were assessed by log-rank comparison of Kaplan-Meier curves. Results: During follow-up, CE included sudden death (1 patient), heart failure (7 patients), atrial fibrillation (6 patients), left ventricular (LV) systolic dimension >4.5 cm (12 patients), LV ejection fraction (EF) <60% (7 patients), right ventricular EF <35% (2 patients) and combination CE (7 patients). Overall, vasodilator use did not predict CE (not significant). However, patients without HTN had higher CE rates with vasodilators than without (p = 0.007), while those with HTN and vasodilators had lower CE rates than those without vasodilators (p = 0.04). Conclusion: Vasodilator use appears to confer no survival benefit in patients with chronic severe MR. The small number of patients with HTN precludes conclusions about modulation of vasodilator effect by HTN. Randomized trials are needed to conclusively evaluate this association.

Rapid Resolution of Massive Lung Abscesses Complicating Tricuspid-Valve Endocarditis

HomeCirculationVol. 114, No. 14Rapid Resolution of Massive Lung Abscesses Complicating Tricuspid-Valve Endocarditis Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBRapid Resolution of Massive Lung Abscesses Complicating Tricuspid-Valve Endocarditis Yok-Ai Que, MD, PhD, Olivier Muller, MD, PhD and Lucas Liaudet, MD Yok-Ai QueYok-Ai Que From the Department of Intensive Care Medicine (Y.-A.Q., L.L.) and the Service of Cardiology (O.M.), University Hospital, Lausanne, Switzerland. Search for more papers by this author , Olivier MullerOlivier Muller From the Department of Intensive Care Medicine (Y.-A.Q., L.L.) and the Service of Cardiology (O.M.), University Hospital, Lausanne, Switzerland. Search for more papers by this author and Lucas LiaudetLucas Liaudet From the Department of Intensive Care Medicine (Y.-A.Q., L.L.) and the Service of Cardiology (O.M.), University Hospital, Lausanne, Switzerland. Search for more papers by this author Originally published3 Oct 2006https://doi.org/10.1161/CIRCULATIONAHA.106.626317Circulation. 2006;114:e523–e524A 33-year-old female intravenous drug abuser presented with fever and acute respiratory failure requiring mechanical ventilation. Chest x-ray and a thoracic computed tomographic scan revealed multiple nodular lesions with cavitation (Figure 1). A transesophageal echocardiogram disclosed a tricuspid-valve vegetation (Figure 2), and blood cultures were positive for Staphylococcus aureus. A diagnosis of tricuspid-valve endocarditis with septic pulmonary emboli (SPE) was made. Antibiotherapy with intravenous flucloxacillin and gentamicin induced a spectacular regression of the lung abscesses, allowing weaning from mechanical ventilation after 8 days and discharge from the hospital after 4 weeks (Figure 1). Download figureDownload PowerPointFigure 1. Repeated computed tomographic scans of the chest from apex to base showing massive, bilateral, nodular lesions with cavitation on admission (A, B, and C). Spectacular improvement of the lesions under appropriate antibiotic therapy was noted after 14 days (D, E, and F), and almost complete resolution was noted after 4 weeks (G, H, and I).Download figureDownload PowerPointFigure 2. Transesophageal echocardiography (4-chamber view) showing a large mobile mass attached to the atrial surface of the anterior leaflet of the tricuspid valve.Infective endocarditis is a serious complication of intravenous drug abuse, with a reported mortality of 5% to 10%.1 In a recent retrospective series of 493 cases of infective endocarditis, 220 (44.6%) occurred in intravenous drug users. The tricuspid valve was most frequently affected (88% of cases), and S aureus was the most frequently encountered pathogen.2 SPE are relatively common in this setting. Intravenous drug users comprised 78% of a cohort of 60 patients with SPE reported in 1978,3 and tricuspid endocarditis was the embolic source in 53% of the cases. Although SPE may be particularly severe and life-threatening, appropriate antibiotherapy may result in rapid resolution of the lung abscesses, as indicated here, and thus such a complication should not be considered an indication for valve surgery in the setting of tricuspid endocarditis.DisclosureDr Liaudet is supported by the Swiss National Fund for Scientific Research (Grant Nr PP00B-68882/1). The other authors have no potential conflicts of interest to disclose.FootnotesCorresponding to Professor Lucas Liaudet, MD, Department of Intensive Care Medicine, BH 10-982, University Hospital, 1011 Lausanne, Switzerland. E-mail [email protected]References1 Moreillon P, Que YA. Infective endocarditis. Lancet. 2004; 363: 139–149.CrossrefMedlineGoogle Scholar2 Martin-Davila P, Navas E, Fortun J, Moya JL, Cobo J, Pintado V, Quereda C, Jimenez-Mena M, Moreno S. Analysis of mortality and risk factors associated with native valve endocarditis in drug users: the importance of vegetation size. Am Heart J. 2005; 150: 1099–1106.CrossrefMedlineGoogle Scholar3 MacMillan JC, Milstein SH, Samson PC. Clinical spectrum of septic pulmonary embolism and infarction. J Thorac Cardiovasc Surg. 1978; 75: 670–679.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails October 3, 2006Vol 114, Issue 14 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.626317PMID: 17015799 Originally publishedOctober 3, 2006 PDF download Advertisement SubjectsImagingValvular Heart Disease

Intraoperative radiofrequency ablation of chronic atrial fibrillation: a left atrial curative approach by elimination of anatomic "anchor" reentrant circuits.

The percutaneous approach to radiofrequency (RF) catheter ablation for curative treatment of atrial fibrillation (AF) is an investigational technique, and the optimal composition of lesion lines is unknown. We tested an intraoperative RF ablation concept with elimination of left atrial anatomic "anchor" reentrant circuits. In 12 patients with an indication for valve surgery and chronic AF, a right atrial-transseptal approach was chosen for access to the left atrium. AF had been present for 4.3 +/- 3.9 years; the left atria measured 56 +/- 7 mm. Under direct vision, contiguous lesion lines were placed endocardially with temperature-guided RF energy applications for treatment of AF with a specially designed probe. The lesion lines were placed between the mitral annulus and the left lower pulmonary vein, further to the left upper pulmonary vein, from there to the right upper pulmonary vein, and finally to the right lower pulmonary vein. The antiarrhythmic ablation procedure lasted 19 +/- 4 minutes. One patient died postoperatively of low cardiac output. During follow-up of 11 +/- 6 months, chronic AF was ablated successfully in 9 of 11 patients (82%). Six patients were in stable sinus rhythm or intermittent pacemaker rhythm, and three patients were in sinus rhythm with intermittent atypical atrial flutter. Intraoperative RF energy application for induction of contiguous lesion lines is feasible. Elimination of anatomically defined "anchor" reentrant circuits within the left atrium prevented chronic AF in > 80% of the patients treated. Intraoperative validation of lesion line concepts for curative treatment of AF may be transferred to percutaneous ablation techniques.

Valvular heart disease in adults. When to call in the surgeon.

Valvular heart disease is now amenable to surgical intervention. Valve surgery needs to be considered at the appropriate time so that patients are not denied the benefit of operation. Patients with indications for surgery should be operated on before progressive left ventricular dysfunction or the complications attendant to valvular heart disease develop. Delay of indicated surgery may increase the operative risk. This does not mean that patients should be referred for surgery before the appropriate indications appear. It does mean, however, that patients with valvular heart disease should be followed for evidence of progressive signs and symptoms attendant to the disease. Clinical and laboratory evidence of valvular and/or ventricular dysfunction determines when surgical intervention is necessary. Once indications for valve surgery appear, prompt referral is indicated.

Heart valve replacement in the elderly.

From January 1973 to December 1976, 70 operations for heart valve replacement were performed on 68 patients aged 65--75 years. These comprised 40 aortic valve replacements, 27 mitral valve replacements, and three aortic and mitral valve replacements. Three patients died within 30 days of operation (early mortality 4.3%), and five died 12 weeks to three years after operation. Four patients showed no improvement. The results were excellent or good in the remaining 56 patients. Valve replacemnt can restore to a useful independent life elderly patients who would otherwise be a burden on costly social and medical domiciliary services. The indications for valve surgery in the elderly should therefore be the same as in any other age group.