Preexisting Valvular Heart Disease Research Articles

Racial and ethnic disparities in the incidence of stroke and mortality in atrial fibrillation: a US nationwide study

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia globally and is associated with increased risks of cardiovascular mortality and ischemic stroke. Prior research has demonstrated racial/ethnic disparities in AF outcomes yet this work has been limited to small cohorts and did not adjust for anticoagulant therapy. Purpose We compared incidence of ischemic stroke and death by race/ethnicity for patients with AF in the Veterans Health Administration (VA), the largest integrated, low-cost, national healthcare system in the US. Methods In this retrospective cohort study we identified those with an outpatient diagnosis of AF and a confirmatory diagnosis ≦ 180 days of their index AF diagnosis enrolled in VA from January 1, 2014 to December 31, 2021, with follow-up for outcomes from the index AF diagnosis date until May 31, 2022. To create a cohort of incident AF cases, we excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis. We also excluded patients with pre-existing valvular heart disease, prior stroke, receiving hospice care or who died within 180 days of index AF diagnosis. We categorized our independent variable as race (i.e., non-Hispanic American Indian / Alaska Native [AI/AN], Asian, Black, or White [reference group]), and ethnicity (i.e., Hispanic). Our primary outcomes were incidence of stroke or death at any point within the study follow-up period. To compare these outcomes by race/ethnicity we conducted a survival analysis, adjusting for anticoagulant use as a time-varying covariate along with sociodemographic factors (age, sex, region, area deprivation index), clinical factors (CHADS2VA2Sc stroke risk and HAS-BLED bleeding risk), and facility type. Results There were 187,080 patients in the final cohort including 0.5% AI/AN, 1% Asian, 9% Black, 4% Hispanic, 85% White; mean age was 73 years. Over a mean study follow-up period of 4.43 years, 65,375 (34.9%) patients died and 24,910 (13.3%) developed stroke. The adjusted hazard ratio [95% CI] for death was lower for Hispanic (0.84 [0.78, 0.91]) and Black (0.94 [0.91, 0.97]) patients than White patients. In contrast, the adjusted hazard ratio for stroke incidence was higher for Black (1.21 [1.16, 1.27]) and Hispanic (1.10 [1.03, 1.17]) patients than White patients. There was no difference observed between AI/AN or Asian and White patients in either outcome. Conclusions In a national cohort of patients with incident AF, we identified significantly higher rates of stroke in Black and Hispanic than White patients even controlling for myriad factors including anticoagulant use. Conversely, racial/ethnic disparities in mortality appear to be eliminated in VA, counter to prior data. Understanding the factors, beyond anticoagulation, driving disparities in stroke outcomes and identifying factors reducing mortality among minority groups is critical to improving overall AF care in the largest integrated US health system.Adjusted Hazard Ratios of Study Outcomes

441.2: Impact of de novo or worsening of pre-existing valvular heart disease in patients referred to the kidney transplant waitlist – a single centre retrospective cohort study.

441.2: Impact of de novo or worsening of pre-existing valvular heart disease in patients referred to the kidney transplant waitlist – a single centre retrospective cohort study.

Clinical Manifestations and Treatment Outcomes of Brucella Endocarditis: A Retrospective Cohort Study at a Tertiary Cardiac Centre in Bengaluru, Karnataka, India

Introduction: Brucella is a rare cause of Infective Endocarditis (IE), requiring prompt early recognition and treatment to prevent life-threatening complications. Diagnosis is often missed or delayed, leading to an increase in cardiac morbidity and mortality. Aim: To analyse the clinical profile, laboratory parameters, cardiac manifestations, management patterns, and outcomes of Brucella endocarditis. Materials and Methods: A retrospective cohort study was conducted at the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangaluru, Karnataka, India on patients with blood culture-confirmed Brucella endocarditis, diagnosed using modified Duke’s criteria between January 2010 and December 2021. The present study evaluated the clinical presentation, treatment modalities, and outcomes. Descriptive statistical analyses were performed. Results: A total of 34 cases were identified during the study period. The mean age of the patients was 35.6±14 years (age range: 15-66 years), with 82.4% males and 17.6% females. Underlying valvular heart disease was present in 82.4% of the patients, while 17.6% had no pre-existing valvular heart disease. Both aortic and mitral valves were involved with equal frequency. All patients presented with fever. Most patients had a normal leukocyte count (61.8%). Thrombocytopenia (32.3%) and pancytopenia (17.6%) were also observed. Large vegetations (>1 cm) were seen in 38.2% of patients, and complications related to IE were observed in 35.2%. The majority of patients (82.4%) were managed medically alone in the acute phase. The antibiotic regimen of doxycycline with rifampicin combined with intravenous gentamicin was used in the majority of the patients. The observed mortality rate was 17.6%. Conclusion: Brucella endocarditis can present with thrombocytopenia/pancytopenia along with normal or reduced leukocyte count. The addition of intravenous gentamicin to oral therapy may reduce relapse rates.

Follow the heart: A tale of possible infective endocarditis in a patient co-infected with Methicillin-resistant Staphylococcus aureus and Severe Acute Respiratory Syndrome Coronavirus 2

Abstract Introduction Methicillin-resistant Staphylococcus aureus (MRSA) is a leading pathogen responsible for bacteremia and valvular endocarditis. In patients with Coronavirus Disease 2019 (COVID-19), MRSA co-infection represents a challenging scenario, with increased morbidity and mortality. Case presentation We present a case of possible valvular endocarditis in a patient with acute COVID-19 and MRSA bacteremia. A 75-year-old woman presented with severe symptomatic aortic stenosis and moderate mitral stenosis. During hospitalization, she developed COVID-19 pneumonia with acute respiratory failure, and temporal and frontal intraparenchymal cerebral hemorrhage. Blood cultures were positive for MRSA, and the patient was started on a specific antibiotics regimen. The patient subsequently developed multi-organ failure and was transferred to the intensive care unit. Repeated computed tomography of the brain was consistent with a new occipitotemporal cortical hypodensity. Transthoracic echocardiography (TTE) showed a small (4 x 4 mm) mass attached to the aortic valve, but with TTE features inconclusive for infective endocarditis. The patient was scheduled for transesophageal echocardiography, but she suffered cardiac arrest, with no response to resuscitation maneuvers. Conclusions This case reveals the diagnostic and therapeutic challenges raised by MRSA and COVID-19 coinfection in a patient with preexisting valvular heart disease.

Acute rheumatic fever in adult patients.

Acute rheumatic fever (ARF) is considered as a disorder of children, and attacks in adults are usually a recurrence of disease acquired in the child’s life. Although the incidence of ARF in children has a decreasing trend in developed countries, resurgent and sporadic epidemics still occur in adults. The first attacks of ARF in adult patients without a childhood history can lead to a diagnostic dilemma.A medical record review in adults at least 18 years of age with an arthralgia complaint fulfilling 2015 revised Jones criteria was performed from January 1, 2000 to December 31, 2019.Eleven ARF patients were identified, including 8 with initial attacks (6 females aged 26–42 years, 33.9 ± 5.3) and 3 pre-existing valvular heart disease with recurrent attacks (2 females aged 38–52 years, 45.0 ± 7.0). In addition to febrile pharyngitis and migratory polyarthritis in initial attacks, pericarditis was encountered in 1, valvulitis in 2, prolong PR interval in 3 and skin involvement in 2 patients with erythema marginatum and IgA vasculitis. All responded to antibiotics and nonsteroidal anti-inflammatory drugs therapy with normalized clinical and laboratory abnormalities, no new-onset carditis, and no recurrent disease during a long-term follow-up (3.8–19.8 years, 12.7 ± 5.4).A sporadic occurrence of adult ARF is observed in southern Taiwan. This disease should be considered by physicians for the differential diagnosis of febrile pharyngitis with arthritis and/or carditis in adults, even in areas with a low incidence of ARF.

Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure (HF) that affects women late in pregnancy or in the early puerperium. There are several definitions for PPCM. While there are numerous potential mechanisms for Peripartum (post-partum) cardiomyopathy, its exact cause remains unknown1, but the etiopathogenesis is likely to be multifactorial. PPCM is uncommon before 36weeks of pregnancy, and afflicted women generally present during the first month after delivery. PPCM should be differentiated from pre-existing cardiomyopathy, undiagnosed congenital heart disease, pre-existing valvular heart disease, myocardial infarction, pulmonary embolism and diastolic heart failure due to hypertensive heart disease. The principles for treating acute HF caused by PPCM are the same as those for acute HF caused by any other cause with some limitations during pregnancy. Prompt treatment is critical. There is no necessity for an early delivery unless the maternal or foetal health has deteriorated. In women who present with advanced HF with haemodynamic instability, urgent delivery, regardless of gestation, may be considered. Because women with PPCM have a significant chance of relapse in subsequent pregnancies, they need comprehensive contraceptive counselling. In general, the prognosis is good, with more than half of the patients regaining LV function spontaneously within six months of giving birth. Our aim is to put forth an in-depth review of the Peripartum Cardiomyopathy in contemporary practice.

Uncommon Pathogen in an Unexpected Host: A Case of Rothia Mucilaginosa Endocarditis in an Immunocompetent Patient without Underlying Valvular Disease

Rothia mucilaginosa, formally known as Stomatococcus mucilaginosus, is a gram-positive coccus that is found as a commensal in the oral cavity and upper respiratory tract. It is an infrequent opportunistic pathogen with very rare infection rates, mostly affecting immunocompromised patients such as patients with severe neutropenia, HIV infection, malignancy, diabetes mellitus, and liver cirrhosis. Infections in immunocompetent individuals are extremely rare, and usually related to pre-existing valvular heart disease, prosthetic valves and indwelling vascular catheters. Other risk factors for Rothia bacteremia include: intravenous drug use (IVDU).

163. Infective Endocarditis in Qatar: Risk Factors, Clinical Characteristics, Microbiology, and Outcomes

BackgroundInfective endocarditis (IE) is a serious and life-threatening disease. The aim of the study is to describe the epidemiology, clinical characteristics and outcomes of patients with IE in Qatar.MethodsPatients were identified from the electronic records of Hamad Medical Corporation hospitals, the national referral center for the State of Qatar. Those aged ≥18 years with Duke Criteria-based diagnosis of IE during the period from January 2015 to September 2017 were included. Data were analyzed using STATA software Version 15.ResultsFifty-seven cases were included, of which 70% were males. Mean age was 51 years (± 16.8). Eleven (19%) were in association with prosthetic valves and 6 (11%) with implantable cardiac devices (Table 1). Fever (84%), dyspnea (46%) and heart failure were the commonest presentations. The majority of patients had preexisting valvular heart disease or intra-cardiac devices (Table 1). Skin infections (10, 18%) were the most prevalent portals of infection, followed by venous catheters, recent valve surgery and implantable cardiac devices (Table 1). Staphylococcus species were implicated in 19 (34%) and Streptococcaceae in 9 (16%); whereas 21 (37%) were culture-negative (Table 2). Left-side IE (49, 86%) was predominant. Acute kidney injury (AKI) (17, 30%) and heart failure (11, 19%) were common complications. The most frequently used treatment regimens included glycopeptides or Β-lactams (Table 2). Only 9 (16%) patients underwent surgical intervention. Fourteen (25%) patients died of any cause before hospital discharge. Logistic regression analysis identified septic shock and AKI as the only risk factors independently associated with in-hospital mortality (Table 3).ConclusionSkin infections are an important risk for IE in Qatar. The majority of patients with IE have preexisting cardiac conditions. Staphylococci are the commonest confirmed bacterial etiology of IE in Qatar, but nearly one-third of cases are culture-negative. Only a small proportion of patients with IE undergo surgical intervention and overall mortality is high. The findings suggest that efforts should be directed toward improving IE prevention strategies in high-risk patients, encourage early microbiological investigations and improved medical and surgical management. Disclosures All authors: No reported disclosures.

Abstract 042: Association Between Preexisting Valvular Heart Disease and Takotsubo Cardiomyopathy Among Hospitalized Patients in the United States

Background: The pathogenesis of Takotsubo Cardiomyopathy (TTCM) remains poorly understood. Several case reports have described the occurrence of TTCM in patients with preexisting valvular heart disease (VHD). We sought to examine the association between preexisting VHD and TTCM in hospitalized patients. Methods: Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), all hospitalizations between 2007 and 2011 with preexisting diagnosis of VHD and admitting diagnosis of TTCM were extracted using ICD-9 CM codes. We compared patients admitted for TTCM who had preexisting VHD to those without. We excluded patients below the age of 18 as well as those diagnosed with TTCM who later underwent percutaneous coronary intervention (PCI). Multivariate logistic regression was used to assess the independent effect of preexisting VHD on both occurrence of TTCM and clinical outcomes (length of stay (LOS), stroke and in-hospital mortality). Results: In our study, 613 (0.06%) out of the 1,084,719 hospitalized patients with preexisting VHD, had TTCM, compared to 13,381 (0.04%) out of the 31,460,000 with no preexisting VHD (p<0.0001). In adjusted models, patients with preexisting VHD had a lower risk of being hospitalized for TTCM in the index hospital admission (adjusted odds ratio (aOR) =0.83, 95% confidence interval (CI) =0.77-0.90), independent of potential demographic, comorbid and lifestyle confounders. However, preexisting VHD was significantly associated with longer LOS (aOR=2.59, 95% CI=1.95-3.23), increased stroke rate (aOR=2.49, 95% CI=1.75-3.54) and higher in-hospital mortality (aOR=1.48, 95% CI=1.05-2.09). Conclusion: In this large, nationwide study, preexisting VHD was associated with worse clinical outcomes in patients hospitalized for TTCM. Our results can guide future clinical decision-making regarding prompt risk factor identification for poor prognosis in TTCM patients. Future prospective studies are needed to further evaluate this association.

CRT-800.53 Association Between Preexisting Valvular Heart Disease and Takotsubo Cardiomyopathy among Hospitalized Patients in the United States

The pathogenesis of Takotsubo Cardiomyopathy (TTCM) remains unknown. Several case reports have described the occurrence of TTCM in patients with preexisting valvular heart disease (VHD). We sought to examine the association between preexisting VHD and TTCM in hospitalized patients. Using the

The year in cardiology 2016: valvular heart disease.

A large number of studies addressing various aspects of the diagnosis and treatment of valvular heart disease (VHD) have been published since the ESC Annual congress in 2015. As expected in this era of rapidly evolving therapeutic modalities and technologies, many scientific contributions are related to the expanded role of percutaneous interventions. New data are now available, consolidating the validity of the transcatheter approach in a variety of subsets of patients and therefore offering new strategies and perspectives in management. The most relevant articles have been selected for this review. It is well known that ageing of the population is associated with a higher prevalence of VHD. A large-scale echocardiographic screening involving 2500 individuals aged > 65 years was conducted to detect undiagnosed VHD ( Figure 1 ).1 Clinically significant (moderate or severe) undiagnosed VHD was identified in 6.4%. In addition, 4.9% of the cohort had pre-existing VHD (a total prevalence of 11.3%). Projecting these findings using population data, the prevalence of clinically significant VHD is estimated to double before 2050. The unique data of this study confirm the scale of the emerging epidemic of VHD, with widespread implications for clinicians and healthcare resources. In this scenario of predominantly elderly people affected by significant VHD, percutaneous modalities of treatment are expected to play a major role. Figure 1 UK population projections of diagnosed and undiagnosed significant valvular heart disease. The OxValve Population Cohort Study. Diagnosed estimates are based on the number excluded from participation in the present study due to a prior diagnosis of valvular heart disease. Undiagnosed estimates are based on the number with newly diagnosed significant valvular heart disease in OxVALVE-PCS. Reproduced with permission from D’Arcy JL et al .1 The mechanisms responsible for aortic valve calcification and development of aortic stenosis (AS) have been explored, and an association between valvular …

Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE Population Cohort Study.

Valvular heart disease (VHD) is expected to become more common as the population ages. However, current estimates of its natural history and prevalence are based on historical studies with potential sources of bias. We conducted a cross-sectional analysis of the clinical and epidemiological characteristics of VHD identified at recruitment of a large cohort of older people. We enrolled 2500 individuals aged ≥65 years from a primary care population and screened for undiagnosed VHD using transthoracic echocardiography. Newly identified (predominantly mild) VHD was detected in 51% of participants. The most common abnormalities were aortic sclerosis (34%), mitral regurgitation (22%), and aortic regurgitation (15%). Aortic stenosis was present in 1.3%. The likelihood of undiagnosed VHD was two-fold higher in the two most deprived socioeconomic quintiles than in the most affluent quintile, and three-fold higher in individuals with atrial fibrillation. Clinically significant (moderate or severe) undiagnosed VHD was identified in 6.4%. In addition, 4.9% of the cohort had pre-existing VHD (a total prevalence of 11.3%). Projecting these findings using population data, we estimate that the prevalence of clinically significant VHD will double before 2050. Previously undetected VHD affects 1 in 2 of the elderly population and is more common in lower socioeconomic classes. These unique data demonstrate the contemporary clinical and epidemiological characteristics of VHD in a large population-based cohort of older people and confirm the scale of the emerging epidemic of VHD, with widespread implications for clinicians and healthcare resources.

Incidence and Risk Factors of Perioperative Stroke in Noncardiac, and Nonaortic and Its Major Branches Surgery

Perioperative stroke, defined as a stroke that occurs during an operation until 30 days postoperatively, is an uncommon but devastating complication. Studies regarding perioperative stroke in noncardiac and nonmajor vessels surgery are scarce. Patients aged 18 years and older who underwent noncardiac, and nonaortic and its major branches surgery between January 2009 and December 2013 were included. A surgeon-matched control study forming a case-to-control ratio of 1:4 was conducted. Patients' characteristics, comorbidities, preoperative and perioperative stroke risks, stroke types, and types of surgical procedure were collected and analyzed by descriptive statistics. Multiple logistic regression analysis was used to identify significant risk factors of perioperative strokes (P <.05). Forty-two out of 55,648 noncardiovascular surgery patients developed perioperative strokes, resulting in an incidence of .075%. Age (adjusted OR 1.04; 95% CI 1-1.08, P = .42), valvular heart disease (adjusted OR 6.18; 95% CI 1.35-28.33, P = .019), previous stroke (adjusted OR 7.06; 95% CI 1.74-28.75, P = .006), emergency surgery (adjusted OR 8.13; 95% CI 2.05-32.25, P = .003), and postoperative hypotension (adjusted OR 5.1; 95% CI 1.11-23.45, P = .036) were significant predictors of perioperative strokes by multivariable analysis. The incidence of perioperative stroke found was comparable to the previous similar studies. Advanced age, pre-existing valvular heart disease, previous stroke, emergency surgery, and postoperative hypotension were the significant risk factors determined in this study.

Antiphospholipid Antibody Syndrome With Valvular Vegetations in Acute Q Fever.

Coxiella burnetii endocarditis is considered to be a late complication of Q fever in patients with preexisting valvular heart disease (VHD). We observed a large transient aortic vegetation in a patient with acute Q fever and high levels of IgG anticardiolipin antibodies (IgG aCL). Therefore, we sought to determine how commonly acute Q fever could cause valvular vegetations associated with antiphospholipid antibody syndrome, which would be a new clinical entity. We performed a consecutive case series between January 2007 and April 2014 at the French National Referral Center for Q fever. Age, sex, history of VHD, immunosuppression, and IgG aCL assessed by enzyme-linked immunosorbent assay were tested as potential predictors. Of the 759 patients with acute Q fever and available echocardiographic results, 9 (1.2%) were considered to have acute Q fever endocarditis, none of whom had a previously known VHD. After multiple adjustment, very high IgG aCL levels (>100 immunoglobulin G-type phospholipid units; relative risk [RR], 24.9 [95% confidence interval {CI}, 4.5-140.2]; P = .002) and immunosuppression (RR, 10.1 [95% CI, 3.0-32.4]; P = .002) were independently associated with acute Q fever endocarditis. Antiphospholipid antibody syndrome with valvular vegetations in acute Q fever is a new clinical entity. This would suggest the value of systematically testing for C. burnetii in antiphospholipid-associated cardiac valve disease, and performing early echocardiography and antiphospholipid dosages in patients with acute Q fever.

Abstract 226: Electrocardiographic and Echocardiographic Changes in Patients Undergoing Liver Transplant Stratified by Outcomes

Background: Association between electrocardiographic (EKG) and echocardiographic (Echo) parameters and outcomes in cirrhotic cardiomyopathy are not clear. Methods: We studied 73 adult patients with liver cirrhosis referred for liver transplantation between January 2007 and December 2013 at a tertiary liver transplant center. A complete 12-lead EKG and Echo was done prior to and after liver transplant. Patients with history of coronary artery disease, pre-existing heart failure and valvular heart disease were excluded. Standard 2D echo and diastolic function parameters were studied. We excluded 10 patients with incomplete data. Results: Mean age was 55± 8yrs, 65% (41 of 63) were men and the mean EF (ejection fraction) was 61±8%. Prevalence of diastolic dysfunction (DD) was 57% (36 of 63), of which 25%(9 of 36) were Stage 1, 67%(24 of 36) were Stage 2 and 8%(3 of 36) were Stage 3, respectively. There were 22(30%) deaths in the follow up period (1132 ± 795 days). Among the survivors, the PR-interval, QRS duration, QTC interval and Left atrial volume index showed statistically significant improvement compared to the deceased subjects. There was a trend towards improvement in DD post-transplant. Mortality was 15% in subjects with improved diastolic function versus 34% with worsening diastolic function (p=0.1). Death was predominantly due to non-cardiac complications (table). Conclusions: Prevalence of DD in cirrhotic cardiomyopathy was 57% in our study. There was a significant improvement in EKG and Echo parameters post-transplant. However, it did not significantly improve outcomes as most of the deaths were due to non-cardiac complications. Incidence of post-transplant major complications

Pulmonary hypertension and leading factors in patients undergoing dialysis.

To determine the frequency and leading factors of pulmonary hypertension among chronic hemodialysis patients. Case series. Hemodialysis Unit, Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi, from September 2011 to March 2012. Patients of either gender aged between 16 to 60 years of age undergoing hemodialysis for at least 3 months not having pre-existing valvular heart disease, chronic lung disease or connective tissue disorder were included. Pulmonary hypertension was prospectively estimated by Doppler echocardiogram on patients undergoing dialysis. Pulmonary artery pressure was calculated on the post-dialysis day and leading factors were compared between patients with and without pulmonary hypertension. A total of 178 patients were included in study with male to female ratio120/58 (2.06:1). The mean age was 33.84 ± 11.9 years. The mean duration of hemodialysis was 23.85 ± 22.48 months. Pulmonary hypertension was found in 76 (42.7%) patients. Out of the studied factors, low serum albumin (< 3.4 mg/dl, p = 0.01) was found to be statistically significant in patients with pulmonary hypertension. Pulmonary hypertension was frequently present in dialysis population (42.7%). This subset of patients had significantly lower albumin levels in serum. More research is needed in its pathogenesis to arrest its course.

Streptococcus bovis bacteraemia: an evaluation of the long-term effect on cardiac outcomes

Streptococcus bovis can lead to bacteraemia, septicaemia, and ultimately endocarditis. The objective of this study was to evaluate the long-term implications of S. bovis endocarditis on cardiac morbidity and mortality. A retrospective cohort study was performed between January 2000 and March 2009 to assess all patients diagnosed with S. bovis bacteraemia from the Belfast Health and Social Care Trust. The primary end-point for cardiac investigations was the presence of endocarditis. Secondary end-points included referral for cardiac surgery and overall mortality. Sixty-one positive S. bovis blood cultures from 43 patients were included. Following echocardiography, seven patients were diagnosed with infective endocarditis (16.3% of total patients); four patients (9.3%) had native valve involvement while three (7.0%) had prosthetic valve infection. Five of these seven patients had more than one positive S. bovis culture (71.4%). Three had significant valve dysfunction that warranted surgical repair/replacement, one of whom was unfit for surgery. There was a 100% recurrence rate amongst the valve replacement patients (n=2) and six patients with endocarditis had colorectal pathology. Patients with endocarditis had similar long-term survival as those with non-endocarditic bacteraemia (57.1% alive vs. 50% of non-endocarditis patients, p=0.73). Streptococcus bovis endocarditis patients tended to have pre-existing valvular heart disease and those with prosthetic heart valves had higher surgical intervention and relapse rates. These patients experienced a higher rate of co-existing colorectal pathology but currently have reasonable long-term outcomes. This may suggest that they represent a patient population that merits consideration for an early surgical strategy to maximise long-term results, however, further evaluation is warranted.

Atypical giant cell arteritis predominantly involving intramural coronary arteries: a case showing refractory dialysis-related hypotension

Giant cell arteritis involving intramural coronary artery branches is rare, and its clinical features remain poorly understood. We report a 56-year-old hemodialysed patient with a history of mitral valve replacement, who presented with "fever of unknown origin" and intractable hypotension. The antemortem diagnosis was very difficult and the autopsy revealed giant-cell-rich vasculitis in arteries in multiple organs. The heart was most severely involved, in which almost all of the intramural coronary artery branches were infiltrated by many multinucleated giant cells, macrophages, and lymphocytes with luminal narrowing, but the epicardial segments of the coronary arteries were spared. Superimposed on the preexisting valvular heart disease, the vasculitic lesions were thought to play a central role in severe cardiac dysfunction resulting in dialysis-related hypotension, which led to fatal non-occlusive mesenteric ischemia. This case highlights the possibility that giant cell arteritis of intramural coronary arteries could be an uncommon underlying cause of refractory dialysis-related hypotension.

Community-based outpatient parenteral antimicrobial therapy (CoPAT) for Staphylococcus aureus bacteraemia with or without infective endocarditis: analysis of the randomized trial comparing daptomycin with standard therapy

ObjectivesAdministering outpatient parenteral antimicrobial therapy in the community setting (CoPAT) is becoming more common with the increasing emphasis on controlling costs. However, few controlled trials have evaluated this treatment modality.MethodsUsing data from a recent randomized trial comparing daptomycin with standard therapy (semi-synthetic penicillin or vancomycin, each with initial low-dose gentamicin) for Staphylococcus aureus bacteraemia and infective endocarditis (SAB/IE), patient characteristics and outcomes were evaluated. Patients receiving their full course of therapy in the hospital setting were compared with those who received some portion outside of the hospital (CoPAT).ResultsAmong the 200 patients, 51.5% received CoPAT. These patients were generally younger (median age 50 versus 54 years, P = 0.028). In the CoPAT group, there tended to be fewer patients with endocardial involvement (8.7% versus 18.6%, P = 0.061) and pre-existing valvular heart disease (7.8% versus 15.5%, P = 0.120). CoPAT patients received longer therapy courses (mean 25.4 versus 13.5 days, P < 0.001) and had higher rates of therapy completion (90.3% versus 45.4%, P < 0.001) and clinical success (86.4% versus 55.7%, P < 0.001). Persisting or relapsing S. aureus was less frequent in the CoPAT group (3.9% versus 15.5%, P = 0.007) and there were fewer deaths (3.9% versus 18.6%, P = 0.001) 6 weeks after the end of therapy. Hospital readmission occurred for 18 of the 103 (17.5%) CoPAT patients. Clinical success rates were similar for CoPAT patients receiving daptomycin (90.0%) or standard therapy (83.0%).ConclusionsWith proper monitoring, stable patients can complete treatment for SAB/IE as outpatients in the community setting. Daptomycin is an appropriate option for this setting.

Incidence of severe ventricular arrhythmias during pulmonary artery catheterization in liver allograft recipients

Liver allograft recipients may develop a hyperdynamic circulation and cardiac electrophysiologic abnormalities. The incidence of severe ventricular arrhythmias in liver allograft recipients during pulmonary artery (PA) catheterization was determined. One hundred five liver allograft recipients were studied prospectively; 5 of the patients with preexisting valvular heart disease, ischemic heart disease, or arrhythmias were excluded. Severe ventricular arrhythmia, defined as 3 or more consecutive ventricular premature beats occurring at a rate of >100 per minute, was observed in 37.0% of the patients during insertion of the catheter and in 25.0% of the patients during removal of the catheter. Two patients developed ventricular tachycardia, and 2 developed ventricular fibrillation; the arrhythmias in these 4 patients did not respond to appropriate pharmacological treatment but resolved promptly after removal of the PA catheter. The catheter transit time from the right ventricle to the pulmonary capillary wedge position was longer in patients with severe ventricular arrhythmia than in those without this arrhythmia (91.6+/-103.6 s versus 53.3+/-18.4 s, P<0.05). In conclusion, patients undergoing liver transplantation have a high risk of developing a ventricular arrhythmia during PA catheterization.