bluuebunny/crossref_metadata_2025 huggingface dataset:
Seven year follow up of subclinical rheumatic disease using WHF criteria
Authors: Bhaya M , Choudhary D , Gupta J , Panwar R B , Panwar V , Gupta B K
Published: November 2023

Background

The prevalence of rheumatic heart disease (RHD) is higher using echocardiographic screening compared with clinical examination. It is proven that clinical screening underestimates the prevalence, but it still remains the cornerstone for the purpose of intervention. Echocardiography can identify subclinical RHD and can be used for subclinical cases and to see progression /regression on follow up. Follow-up data of children with subclinical lesions are very much needed before implementing large scale screening programs in endemic regions. We are submitting the 7 year follow up data for subclinical RHD who were on RF prophylaxis.

Method

A total of 3000 school going children were screened echocardiographically during November 2015 to December 2018 for subclinical rheumatic heart disease using WHF criteria. Subjects with subclinical rheumatic heart disease were given prophylaxis for rheumatic fever in form of injection Benzathine penicillin or oral penicillin or tablet erythromycin depending upon tolerance and acceptance. These cases were followed up at 2-year and 7-year for echocardiographic evaluation and compliance to the prophylaxis.

Results

Out of 3000 cases screened, 114 were found to be having subclinical rheumatic heart disease. 39 subjects turned up for 2-year follow up and 13 subjects turned up for 7-year follow up(Table 1). All 13 were on rheumatic fever prophylaxis. 23% ( 3 out of 13) turned to be with normal echocardiography findings using WHF 2012 criteria.

Limitation: Children who were not taking prophylaxis were not evaluated echocardiographically, therefore comparison could not be done.

Conclusion

Our study shows screening of school going children by echocardiography can detect subclinical rheumatic heart disease and rheumatic fever prophylaxis in such cases can results in reversion of the lesion and prevention of progression of RHD.
Prognostic implications of papillary muscle delayed hyperenhancement in dilated cardiomyopathy patients
Authors: Beijnink C , Raafs A G , Vos J L , Rodwell L , Heymans S R B , Nijveldt R
Published: November 2023

Background

Similar to left ventricle (LV) myocardial delayed hyperenhancement (HE), papillary muscle delayed hyperenhancement (papHE) at cardiac magnetic resonance (CMR) may indicate fibrotic or infiltrative processes. The prevalence in patients with non-ischemic dilated cardiomyopathy (DCM) and its impact on outcome are unknown.

Objectives

We aimed to determine the prevalence of papHE in an outpatient DCM cohort with longitudinal follow-up.

Methods

From the Maastricht Cardiomyopathy Registry, we included 528 consecutive patients who underwent Late Gadolinium Enhancement (LGE) Cardiac Magnetic Resonance imaging (CMR), and both papHE and papillary tip delayed hyperenhancement (tipHE) were assessed. The primary outcomes were all-cause mortality, sudden cardiac death, life-threatening arrhythmia, and hospitalization for heart failure (HFH). Unadjusted Kaplan Meier curves were constructed and compared using log-rank tests. PapHE was related to outcomes, using univariable and multivariable Cox regression analysis, correcting for clinical covariables (age, sex, and LV ejection fraction). In a second model, we corrected for myocardial HE, on top of the covariables included in the first model. Mitral valve regurgitation was assessed during follow-up echocardiography in 409 patients (77%).

Results

Three hundred and twenty five patients (62%) had tipHE and 131 patients (25%) had papHE. The median follow-up duration was 5.6 (IQR 3.5-9.0) years. PapHE was associated with all-cause mortality (HR=1.76, 95% CI 1.04-2.97), sudden cardiac death (HR=2.23, 95% CI 1.10-4.54) and HFH (HR=2.42, 95% CI 1.16-5.06), but not with life-threatening arrhythmias, after correction for clinical covariables. The presence of isolated tipHE was not associated with adverse outcomes. The correlation of myocardial HE was stronger than that of papHE, specifically with sudden cardiac death (HR=2.40, 95% CI 1.10-5.23 for myocardial HE) and life-threatening arrhythmias (HR=2.97, 95% CI 1.04-8.46 for myocardial HE). Additional correction for myocardial HE rendered the correlation between papHE and the studied outcomes insignificant. Finally, papHE did not correlate to mitral regurgitation.

Conclusions

PapHE is present in 25% of DCM patients. The presence of papHE correlated with sudden cardiac death and HFH, still myocardial HE remains a stronger predictor. Our results support the incorporation of myocardial HE in implantable cardioverter-defibrillator guideline recommendations. Future studies should investigate if the addition of PapHE helps to improve such guidelines further.
Prevalence of pulmonary hypertension in aortic regurgitation and its influence on outcomes
Authors: Ratwatte S , Playford D , Stewart S , Strange G , Celermajer D
Published: November 2023

Background

Pulmonary hypertension (PHT) is known to complicate left heart diseases (LHD) including left sided valvular pathologies such as aortic regurgitation (AR). However, there is a paucity of data on the prognostic importance of PHT in AR patients.

Purpose

We aimed to describe the prevalence and prognostic importance of PHT in adults with "isolated" ≥ moderate AR.

Methods

In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000-2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50%, with moderate or greater AR and without severe aortic stenosis or prior aortic valve replacement, were included (n= 8392). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 3.1 years, interquartile range 1.5-5.7 years).

Results

Subjects were aged 74±14 years and 58.4% (4901) were female. Overall, 1417 (16.9%) had no PHT (eRVSP<30.00mmHg); and 3253 (38.8%), 2249 (26.9%), 893 (10.6%) and 580 (6.9%) had borderline (30.00-39.99mmHg), mild (40.00-49.99mmHg), moderate (50.00-59.99mmHg) or severe PHT (>60.00mmHg), respectively. Mean eRVSP was slightly higher in females than males (41±13 vs 39±12mmHg, p<0.0001) and increased with age in both sexes. A typical phenotype of "left heart disease" was evident with E:e’ and the proportion of patients with RV functional impairments increasing progressively, from no PHT to severe PHT (p<0.0001, for all). After adjustment for age and sex, the risk of long-term mortality increased as eRVSP increased (adjusted hazard ratio (aHR) 1.20, 95% confidence interval 1.06-1.36 in borderline PHT, to aHR3.32, 95%CI 2.85-3.86 in severe PHT) (Figure 1). These trends were maintained on a sensitivity analysis excluding patients with ≥moderate mitral regurgitation (n=6753), though only became significant from mild PHT onwards (aHR 1.13, 95% CI 0.98-1.30 in borderline PHT, to aHR3.51, 95%CI 2.94-4.18 in severe PHT). Using decile distribution of eRVSP a mortality threshold seen from mild PHT onwards (eRVSP 41.36-44.15mmHg; aHR1.41, 95%CI1.17-1.68) (Figure 2).

Conclusions

In patients with ≥moderate AR, PHT is associated with a progressive risk of mortality, even in those with mild PHT.Adjusted Risk for All-Cause MortalityThreshold for Mortality
Sex-specific differences in patients with significant aortic regurgitation
Authors: Gonzalez Gomez A , Monteagudo J M , Garcia Martin A , Hinojar R , Casas E , Antonana-Ugalde S , Martinez-Vives P , Ramos P , Martinez-Moya R , Jimenez Nacher J J , Zamorano J L , Fernandez-Golfin C
Published: November 2023

Background

Significant aortic regurgitation (AR) leads to left ventricular (LV) remodelling and poor outcomes if untreated; however, data on sex-differences in the setting of significant AR is scare.

Purpose

To examine contemporary clinical and echocardiographic differences between men and women with significant chronic AR.

Methods and results

Consecutive patients with significant AR evaluated in a heart valve clinic following a comprehensive clinical and imaging protocol were included. Comparison was performed between genders. A total of 206 patients with significant AR were included (130 grade III, 76 grade IV AR) (mean age 69 years, 49% women). Mean follow-up was 3.7 years. Women showed similar comorbidities, but were older (66.5 vs 71.4, p=0.017), and more symptomatic. Women were smaller in terms of height, weight and surface area, showing significantly smaller volumes and diameters (LVEDD 52 ± 6.2 mm men vs 47.0 ±6.7 mm women, p<0.001). However, when diameters were normalized, no significant differences were seen between men and women. Hospital admissions due to heart failure and number of surgeries were not significantly different between genders.

Conclusion

In patients with significant AR, indication for intervention in guidelines is based on the same values for both men and women. However, women were more symptomatic and showed significantly smaller volumes and diameters. Indexed values should be considered in decision making taking into account differences in gender.
Arrhythmic form of mitral valve prolapse: presentation, risk stratification and management
Authors: Elgharably Y , Frati G , Mahrous M R , Asfour A , Heikal A , Kazamel G
Published: November 2023

Background

Mitral valve prolapse (MVP) is a common finding that has been considered as benign condition for a long time. However, some anatomic forms have been recently recognized to be associated with life-threatening ventricular arrhythmia and sudden cardiac death (SCD), recently known as arrhythmic MVP (AMVP).

Objectives

This study is aiming to clinically characterize and risk stratify patients with malignant phenotype of MVP of high risk for ventricular arrhythmia which may lead to SCD. We aim to explore characteristics and assess potential markers for MVP induced ventricular arrhythmia that might need monitoring and follow up with medical or invasive treatment as implantable cardioverter-defibrillator, catheter ablation or even surgical repair.

Methods

A prospective cohort study of 45 (age 35±8, 29 females), consecutive patients with MVP and/or mitral annular disjunction (MAD) and comprehensive clinical arrhythmia on resting electrocardiography (ECG) or 48-hours Holter monitoring , Doppler echocardiography and contrast based cardiac magnetic resonance (CMR) characterization were identified. Patients were followed-up for a period of maximum one year to identify any further management needed.

Results

Frequent ventricular arrhythmia was evidently seen associated to MVP (69% with at least ventricular ectopy ≥5%), as well as complex ventricular arrhythmia (31% with sustained or non-sustained ventricular tachycardia ) P<0.001. AMVP was strongly associated with premature ventricular contractions (PVCs) having Right bundle branch block (RBBB) morphology on ECG and late gadolinium enhancement (LGE) on CMR (all p<0.05). Furthermore, it was shown to be associated with bileaflet prolapse and higher left ventricular volumes, however not statistically significant. On Follow-up, Out of 36 patients with ventricular arrhythmia, 64% were controlled on medical anti-arrhythmic and some others were referred either for ablation after worsening of symptoms despite of medical treatment (27.8%), implantable cardioverter-defibrillator device for secondary VT prophylaxes (5.6%) or surgery (2.8%) due to progression in mitral regurgitation severity and deterioration of symptoms.

Conclusion

In this small cohort study, characteristic form of MVP was found to be associated with ventricular arrhythmia more common in the form of frequent PVCs and less common in the complex form. Although majority of patients were controlled on medical treatment, few patients required further invasive management despite of medical treatment . Thus, arrhythmia associated with a special form of MVP could be life threatening and needs close monitoring, long follow-up and proper management approach to prevent SCD. Large prospective studies with comprehensive approach and long term follow up is pivotal. CMR T1 mapping and electro anatomical CARTO mapping could help in better detection and proper defining of arrhythmia substrate in future studies.AMVP illustration
M-mode proximal iso-velocity surface area-based dynamics of instantaneous flow rate and its implications for degenerative mitral regurgitation quantification
Authors: Ge Z , Hu C , Zhao S , Tian F , Dong L , Wang Y , Chen H , Kong D , Pan C , Shu X , Ge J
Published: November 2023

Background

Instantaneous flow rate of degenerative mitral regurgitation (DMR) showed dynamic changes. However, inconsistencies exist across literatures about the timing of measurements for flow convergence in proximal iso-velocity surface area (PISA) calculation. While the 2017 ASE guideline suggested measurement of PISA radius and velocity should be performed at simultaneous moments of the regurgitant phase (PISApair), a few studies used max PISA radius (PISAmax) to calculate regurgitant volume and showed poor agreement with cardiac magnetic resonance (CMR) results.

Purpose

This study aimed to compare the above methods with M-mode PISA, thus to investigate the effect of instantaneous flow rate on the agreement of the diagnosis of severe mitral regurgitation (sMR).

Methods

We prospectively enrolled 75 DMR patients with a) at least mild MR, b) single and non- eccentric MR jet. Regurgitant volume (RVol) was calculated using three PISA methods, respectively. In 25 patients who received CMR, RVol was calculated using volumetric method. The correlation and agreement of RVol among three PISA methods and CMR were compared. The agreements of the diagnosis of sMR between PISA methods and ASE multi-parameter algorithm were analyzed using Cohen’s kappa analyses.

Results

The curve of instantaneous flow rate of DMR displayed unimodal pattern with at the mid-late systolic phase. The correlation of RVol between PISA methods and CMR were moderate for PISAmax (r = 0.77) and strong for PISApair and M-mode PISA ( r = 0.80 and 0.87, respectively). PISAmax derived RVol was larger than that of CMR (69.1 ± 37.1 mL versus. 49.0 ± 29.0 mL, P = 0.002). Compared to the ASE algorithm, only PISAmax significantly overestimated the percentages of sMR (74.7% versus 54.7%, P =0.010), but both PISAmax and PISApair showed moderate consistency (Kappa coefficient (k): 0.496 and 0.525, respectively). A strong agreement was found between M-mode PISA and the ASE algorithm with regard to the diagnosis of sMR (k = 0.867, P <0.05).

Conclusion

Based on the unimodal pattern of instantaneous flow rate in DMR patients, PISAmax significantly overestimated RVol and may expose a significant proportion of DMR patients to MR surgery.
Hemodynamic implications of transcatheter tricuspid valve repair in HFpEF Patients - HERACLES-HFpEF
Authors: Kresoja K P , Rommel K P , Rosch S , Kister T , Schoeber A , Roeder M V , Schlotter F , Besler C , Unterhuber M , Gutberlet M , Thiele H , Lurz P
Published: November 2023

Background

Patients with severe tricuspid regurgitation (TR) and heart failure with preserved ejection fraction (HFpEF) have been suggested to respond favourably to transcatheter edge-to-edge tricuspid valve repair (TEER), but the mechanisms remain poorly understood.

Purpose

The aim of this study was to investigate the pathophysiological implications of TV-TEER in patient with HFpEF and severe TR.

Methods

This was a prospective interventional single arm trial that included 20 HFpEF patients with invasive evidence of increased filling pressures (i.e. left-ventricular enddiastolic pressure [LVEDP] >15 mmHg and preserved ejection fraction i.e. LVEF ≥50%) at a single centre. All patients received transthoracic echocardiography and cardiac magnetic resonance imaging (MRI) immediately before and 1-month after TV-TEER. During the TV-TEER procedure LV pressure-volume loops were recorded by using a conductance catheter (Figure 1A). The primary outcome was the periprocedural change in the ratio of LVEDP to left-ventricular end-diastolic volume (LVEDV) as surrogate for preload independent diastolic function. The secondary outcomes included single-beat estimated end-diastolic pressure volume-relationships (EDPVRs), and LV distending pressure (calculated as LVEDP-mean right atrial pressure) as well as changes at 1-month in LVEDV and right ventricular EDV (RVEDV) as surrogates for ventricular interdependence.

Results

Between 02/2021 to 12/2022 20 patients (median age 78, IQR 72 to 83 years, 65% ♀) were included in the prospective HERACLES-HFpEF trial. All patients successfully underwent TV-TEER with a median TR grade reduction of 2 (IQR 2 to 1) on a five-grade scaling. Despite a periprocedural increase in LVEDV (p<0.001), LVEDP remained stable after successful TV-TEER (p=0.12). This led to a significant reduction of the primary endpoint LVEDP/LVEDV (p=0.001, Figure 1B).

Load independent diastolic function improved with a rightward shift of the EDPVR (Figure 1C). LV distending pressure increased implying stronger LV distension in the restricted pericardial space. At one-month follow-up MRI (available for 17 patients) LVEDV increased (∆ median +5 ml, p=0.017), while RVEDV decreased (∆ median -17 ml, p=0.031). Interestingly, there was a significant inverse correlation between the change of LVEDV and RVEDV, again implying more favourable LV to RV interaction (Figure 1C).

Conclusion

TV-TEER in HFpEF patients leads to an immediate periprocedural increase in LV volume at maintained filling pressures. The improved diastolic function is possibly attributable to a more favourable LV to RV interaction where RV volumes are reduced to allow for the LV to better distend in the limited pericardial space. TV-TEER might pose a potential therapy for a subgroup of HFpEF patients with severe TR, meriting validation in prospective endpoint driven clinical trials.Figure 1
Functional volume distribution in tricuspid regurgitation associated right heart failure
Authors: Rommel K P , Besler C , Unterhuber M , Kresoja K P , Noack T , Kister T , Brener M , Fudim M , Abdel-Wahab M , Leon M , Thiele H , Burkhoff D , Lurz P
Published: November 2023

Background

Tricuspid regurgitation (TR) associated right heart failure is a significant challenge, and while tricuspid edge-to-edge repair (TEER) has been suggested to improve outcomes, patients remain at substantial residual risk. Thus, adjunctive therapies to treat associated right heart failure are warranted. Sympathetically mediated venoconstriction with subsequent changes in functional volume distribution with increases in stressed blood volume (SBV) ( the volume compartment which generates intravascular pressure) has been shown to importantly mediate hemodynamic derangements in heart failure and might pose an attractive adjunctive treatment target (e.g. by means of splanchnic denervation).

Objectives

This study aimed to elucidate the determinants of unfavorable functional volume distribution in patients with TR-associated right heart failure and investigate the prognostic role of SBV after TEER.

Methods and Results

A total of 279 patients underwent right heart catheterization (RHC) prior to TEER. SBV was estimated (eSBV) from hemodynamic variables fit to an extensively validated and comprehensive cardiovascular model. eSBV was associated with obesity, renal and hepatic dysfunction, and cardiac remodeling (p < 0.05 for all). Hemodynamically, eSBV correlated with pulmonary artery (PA) and cardiac filling pressures, as well as right ventricular-PA coupling (p < 0.05 for all). After TEER, patients with eSBV above the median demonstrated less reduction in right atrial pressures, peripheral edema, and ascites compared to lower eSBV patients (p < 0.05 for all). Higher eSBV was a powerful predictor of the occurrence of death and heart failure hospitalization during a median follow-up of 618 days (p < 0.05 for all) independent of all clinical, imaging, and invasive hemodynamic parameters.

Conclusion

In severe TR, eSBV is associated with obesity, renal and liver dysfunction, more severe heart failure, attenuated reduction of venous congestion after TEER, as well as adverse clinical outcomes. Estimation of SBV should be incorporated in future trials in the field to identify patients in need of adjunctive therapies and test its role as a potential treatment target.
Assessment of multicausality in tricuspid regurgitation
Authors: Segovia Reyes J , Marquez Camas P , Soler Gonzalez M , Arroyo Monino D F , Garcia Rodriguez L , Alegre Garcia G , Rodriguez Cordoba A , Palma Marti L , Angullo Gomez M , Gonzalez Aguado N , Contreras Munoz A , Diaz Exposito A , Gomez Doblas J J , Jimenez Navarro M F , Rodriguez Capitan J
Published: November 2023

Introduction

Tricuspid regurgitation (TR) is a condition with multiple etiologies. The increased clinical knowledge of this pathology in recent years has led to a paradigm shift in its classification, with the latest literature advocating for stratification based on the pathophysiological profile beyond the classical division into primary and secondary or functional causes. In this study, we aimed to evaluate the possible concomitant causes of TR in a large series of patients classified into different groups according to their clinical profile.

Methods

Multicenter and retrospective study that included a series of consecutive patients with significant TR (moderate to severe or greater) diagnosed between 2002 and 2017. The patients were classified by the type of TR based on their main clinical context. For this purpose, we followed the step-by-step classification proposed by Topilsky et al so that the type of TR was defined in the first step that met the established criteria. Subsequently, an individual analysis of each of the obtained groups was performed to detect other possible causal mechanisms of TR.

Results

A total of 778 patients with significant TR were included and classified into 6 groups according to their clinical profile following the proposed classification (see attached image). Functional TR associated with left-sided valvular disease (56.16%) was the most frequent group observed. The attached table shows the different groups and concomitant pathologies. In those with primary etiology (congenital and acquired), only 33.33% and 25%, respectively, had no other etiology defined. Among the functional causes, those with TR associated with left-sided valvular disease did not present other causal mechanisms in 62.92% of cases, and 66.66% of cases in the group with TR associated with ventricular dysfunction did so. The functional groups associated with pulmonary hypertension and atrial cause did not present other notable concomitant causes as they were at the end of the classification.

Conclusions

In a large series of patients with significant TR, up to 31.87% of the sample showed other possible concomitant causes of TR apart from their main clinical profile, and this percentage was even higher in patients with primary causes. Given that the clinical course of this entity has been shown to differ according to the type of TR, this suggests that in approximately one-third of our patients with significant TR, a more descriptive and exhaustive etiological classification may be necessary to understand their prognosis and establish the best therapeutic strategy.Flow-chart and classification.Concomitant pathologies.
Clinical risk factors and prediction model for infective endocarditis in patients with gram-positive bacteremia
Authors: Panthong S , Takkavatakarn K , Sitticharoenchai P
Published: November 2023

Introduction

Gram-positive bacteremia (GPB) is a common condition in clinical practice that potentially leads to infective endocarditis (IE), a high morbidity and mortality disease. Clinicians still encounter challenges in determining the likelihood of developing IE in GPB patients. Comprehensive and invasive cardiac investigations in every patient with GPB for IE could be unnecessary and potentially harmful while missing proper investigations might result in the delay or misdiagnosis of this fatal condition.

Objective

We aimed to determine the significant clinical risk factors and develop the prediction model for IE in patients with GPB.

Methods

Data were obtained from medical records of hospitalized adult patients with GPB in our hospital from January 2016 to December 2020. IE was defined by the ‘definite’ group according to modified Duke criteria. The cohort was divided into training (80%) and test (20%) sets. We identified the association between clinical risk factors and the development of IE by logistic regression analyses. Significantly associated clinical risk factors in multivariate analysis were used in the prediction model. The area under the receiver operating characteristic curve (AUROC) was utilized to evaluate model performances.

Results

A total of 794 patients with GPB were included in the study. IE was diagnosed in 89 patients (11.2%). Among 21 selected clinical risk factors from univariate analysis, 10 variables, including the unknown origin of bacteremia, mechanical and bioprosthetic heart valve, duration of symptoms more than 7 days, presence of Roth spot, neurological symptoms, murmur, heart failure, number of positive hemoculture more than 2 specimens, and Staphylococcus aureus septicemia, were significantly associated with IE in multivariate analysis (Figure 1) and were utilized in the prediction model. The AUROC of prediction models were 0.943 and 0.865 in training and test sets, respectively.

Conclusions

Our prediction model based on clinical risk factors can precisely predict IE in patients with GPB. Using this model allows clinicians to address patients at risk and guide decision-making in which cases need an urgent and comprehensive workup for IE or a wait-and-see strategy.Figure 1
Left-sided native valve infective endocarditis concomitant with severe valvular regurgitation: Prevalence, characteristics and prognostic factors
Authors: Lopez Diaz J , Lozano A , Cabezon G , De Miguel M , Pulido P , Vilacosta I , Olmos C , Saez C , Gomez I , San Roman J A
Published: November 2023

Background

The characteristics of patients with left-sided native valve infective endocarditis and severe valvular regurgitation has never been studied.

Purpose

To analyze the prevalence of severe valvular regurgitation in patients with left-sided infective endocarditis, to describe in detail their characteristics and to determine the prognostic factors of these patients.

Patients and methods

We included in an ongoing multipurpose database, all patients with definite left-sided infective endocarditis admitted in three Spanish tertiary hospitals from 2005 to 2022. We describe the clinical, epidemiological, microbiological, echocardiographic characteristics of patients with severe valvular regurgitation and compared it with those without it. We also analyzed the independent factors of in-hospital mortality of these patients.

Results

Of a total of 874 patients with left-sided native valve infective endocarditis of our series, 564 had severe valvular regurgitation (65%). Comparison between patients with and without severe valvular regurgitation is shown in figure 1. Age (HR 1.035 95% CI 1.02-1.05), S. aureus (HR 2.26; 95% CI 1.26-4.1), vegetations (HR 3.7; 95% CI 1.2-11.4), heart failure (HR 2.76; 95% IC 1.5-5.1), renal failure (HR 3.1; 95% CI 1.9-4.9) and septic shock (HR 4.3; 95% CI 2.29-8) were the independent factors of in hospital mortality. On the contrary, cardiac surgery is an independent protector factor of mortality (HR 0.35; 95% CI 0.21-0.59).

Conclusions

A very high proportion of patients with definite left-sided infective endocarditis have severe valvular regurgitation in our series. Despite important epidemiological, clinical and echocardiographic differences with patients without it, the short-term prognosis is similar Surgery is an independent protective factor in these patients.
Mitral valve replacement versus repair and long-term risk of infective endocarditis: a nationwide study
Authors: Alhakak A , Butt J H , Havers-Borgersen E , Smerup M H , Kober L , Fosbol E L
Published: November 2023

Background

There is a paucity of data regarding mitral valve (MV) repair versus MV replacement and the associated risk of infective endocarditis (IE). Further research is needed to optimise patient selection and determine the importance of using prophylactic antibiotics.

Purpose

To examine the long-term risk of IE in patients undergoing MV repair, compared with a matched population of patients undergoing MV replacement as well as the background population.

Methods

All patients undergoing MV repair from 2000 to 2020 with no history of IE were identified using Danish nationwide registries. Those patients were matched to patients undergoing MV replacement in a 1:1 ratio as well as the background population in a 1:4 ratio based on age, sex, and year of procedure. The Aalen-Johansen estimator and multivariable Cox regression models were used to examine the long-term risk of IE.

Results

After matching, the study population included 1,797 patients undergoing MV replacement, 1,797 undergoing MV repair, and 7,188 matched controls from the background population. The median age of the study population was 67.8 years (percentile[p]25-p75: 57.8-74.7), and 45.1% were females. Patients with MV replacement were significantly more comorbid, compared with patients with MV repair and the control group, which included ischaemic heart disease, heart failure, atrial fibrillation, stroke, diabetes, chronic renal disease, and chronic obstructive pulmonary disease.

During a median follow-up of 7.7 years (p25-p75: 4.0-13.5), 134 (7.5%) with MV replacement, 57 (3.2%) patients with MV repair, and 27 (0.38%) in the control group were hospitalised with IE.

The median follow-up time from date of procedure to IE admission was 3.5 years (p25-p75: 0.82-7.1) in the MV replacement group, 2.4 years (p25-p75: 0.61-6.6) in the MV repair group, and 8.2 years (p25-p75: 5.3-12.4) in the control group.

In patients with MV replacement, MV repair, and the control group, the 1-year cumulative incidences of IE (Figure) were 7.5% (95% CI: 6.3-8.7%), 3.2% (95% CI: 2.4-4.1%), and 0.38% (95% CI: 0.25-0.54%), respectively.

The 10-year cumulative incidences of IE (Figure) were 9.4% (95% CI: 7.9-11.1%), 3.9% (95% CI: 3.0-5.0%), and 0.56% (95% CI: 0.38-0.82%) in patients with MV replacement, MV repair, and the control group, respectively.

After multivariable adjustment, MV replacement was associated with an increased 10-year rate of IE, compared with MV repair (hazard ratio 2.4 [95% CI: 1.8-3.3]), while the control group was associated with a lower 10-year rate, compared with MV repair (hazard ratio 0.14 [95% CI: 0.085-0.23]).

Conclusion

In this nationwide study, MV replacement was associated with a twofold increased 10-year rate of infective endocarditis, while matched controls from the background population were associated with a significantly lower 10-year rate of infective endocarditis, compared with MV repair.Figure
Role of thoracoabdominal imaging on diagnosis and management in patients with suspected infective endocarditis
Authors: Papadimitriou-Olivgeris M , Guery B , Rotzinger D , Kamani C , Fahrni G , Prior J , Ianculescu N , Auberson D , Tzimas G , Hugelshofer S , Tozzi P , Kirsch M , Monney P
Published: November 2023

Background/Introduction

Embolic events (EEs) are a common complication of infective endocarditis (IE) and their presence can impact diagnosis and modify the therapeutic plan.

Purpose

The present study aimed to describe the role of thoracoabdominal imaging (TA-Im) on diagnosis and management of patients with suspected IE.

Methods

This study was conducted at a university hospital, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria.

Results

Among 966 episodes with IE suspicion and TA-Im, 740 (77%) contrast-enhanced CT, 158 (16%) 18F-FDG PET/CT and 68 (7%) non-contrast-enhanced CT. The majority of patients (528; 55%) were without thoracoabdominal symptoms. At least one EE was found in 205 (21%) episodes. Based on TA-Im findings, the diagnosis was reclassified from rejected to possible or from possible to definite IE in 6 (1%) and 10 (1%) episodes, respectively [2 (0.5%) and 5 (1%) in asymptomatic episodes, respectively]. Table shows the type of embolic events and their impact on diagnosis in episodes with suspected IE. Among the 413 patients with possible or definite IE, at least one EE was found on TA-Im in 143 (35%) episodes. Together with the presence of left-side valvular vegetation >10mm, the results of TA-Im established a surgical indication (prevention of embolism) in 15 (4%) episodes, 7 of which were asymptomatic. Among the subgroup of episodes (n=127) with left-side vegetation >10mm, TA-Im established a surgical indication in 12% of episodes (15 patients), 10% among asymptomatic episodes (7 out of 73). Figure shows the changes in diagnostic classification and management due to TA-Im results in patients suspected (A) and those with IE (B).

Conclusion

TA-Im performed in asymptomatic patients with IE suspicion improved the diagnosis of IE in only a small proportion of patients; this proportion was similarly low in symptomatic patients. The role of systematic TA-Im in the clinical management of asymptomatic IE patients remains unclear, since it identified a new indication for valvular surgery in only a small proportion of patients. The scenario, where the benefit of TA-Im on management is a patient with a vegetation >10mm; in those patients, systematic TA-Im may lead to a new surgical indication in 10% of cases.Embolic eventsDiagnosis and mangement
Does the use of anticoagulation or antiplatelet therapy increase cerebrovascular events in patients with infective endocarditis - a systematic review and meta-analysis
Authors: Caldonazo T , Musleh R , Moschovas A , Kirov H , Witte O , Franz M , Faerber G , Doenst T , Diab M , Guenther A
Published: November 2023

Background

Management of anticoagulant and antiplatelet therapy in patients with infective endocarditis (IE) remains challenging. We aimed to evaluate the impact of antiplatelet and anticoagulant therapy on cerebrovascular events (CVE) and mortality in IE-patients.

Methods

Assessing three databases (MEDLINE, EMBASE, and Cochrane Library), we performed a systematic review and meta-analysis of studies comparing patients with prior and/or ongoing use of antithrombotic therapy (anticoagulation or antiplatelet) versus those without any antithrombotic therapy during IE course. Primary outcome was CVE. Secondary outcomes were perioperative and mid-term (>6 months) mortality, intracranial hemorrhage (ICH), and systemic thromboembolism. Inverse variance method was performed.

Results

Twelve studies with a total of 11,960 patients were included. The primary endpoint (CVE) was not different between the anticoagulation or the antiplatelet group and the control group. Perioperative mortality was lower in the anticoagulation group compared to the control group (OR= 0.74, 0.57-0.96, p=0.03). There was no significant difference in the incidence of ICH between the anticoagulation or antiplatelet group and the control group.

Conclusion

The results suggest that the prior and/or ongoing use of anticoagulants or antiplatelets in patients with IE was associated with similar rates of CVE in general and of ICH in particular. Lack of information about the indications for stopping or continuing antithrombotic therapy in the majority of the included studies is a limitation of this meta-analysis, showing the necessity of a randomized setup.
Blood cardioplegia may be better than crystalloid cardioplegia during cardiac surgery for infective endocarditis
Authors: Caldonazo T , Safarov R , Doenst T , Moschovas A , Kirov H , Kaluza M , Schneider U , Faerber G , Diab M
Published: November 2023

Background

Cardioplegia is an indispensable element in cardiac surgery for left sided infective endocarditis (IE). Crystalloid cardiolegia (CC) as a single or dual-dose is more attractive in complicated IE surgery than repeated, every 15-20 min, administration of blood cardioplegia (BC). Recently, blood cardioplegia was shown to reduce the systemic inflammatory response to cardiopulmonary (CPB) compared to crystalloid cardioplegia. As the systemic inflammatory response after surgery for IE endocarditis is more exaggerated than in non-IE valve surgery, it is important to investigate impact of the two solutions on outcome after IE surgery.

Methods

We retrospectively analyzed data of all patients (n=581) with endocarditis who underwent cardiac valve surgery at our institution between January 2007 and March 2018. The primary endpoint was 30-day mortality, secondary endpointwas the length of intensive care unit (ICU) stay. Nearest neighbor propensity matching with a caliper of 0.01 was performed to adjust for differences in basal characteristics between patients who received Calafiore BC vs Bretschneider CC.

Results

Patients who received CC were older (67 vs 63, p<0.01) had greater incidence of large vegetations (42.7% vs 32.3%, p<0.01), prosthetic valve endocarditis (30.8% vs 17.3%, p<0.01) and mitral valve endocarditis (54.6 vs 43.6 p<0.01). Logistic regression in the raw data revealed a higher mortality rate and longer LOS in ICU for the patients who received CC. After matching, CC was still associated with higher 30-day mortality (24.4% vs 15.9%, p=0.01) and longer ICU-stay (median: 6, IQR: 9 vs median: 3, IQR: 6, p<0.01).

Conclusions

Administration of blood cardioplegia during cardiac surgery for infective endocarditis may be associated with lower 30-day mortality and shorter ICU-stay compared to using crystalloid solution.
Do we need to improve the general oral health of our population to reduce the risk of Infective Endocarditis?
Authors: Davies A D , De Kare-Silver C , Bhamra N B , Mccue M M , Suarez C S , Das S D , Ambekar S A , Bunet A B , Uppal R U , Nanayakkara L N , Woldman S W , Primus C P
Published: November 2023

Background

Emphasis is placed on the link between oral health and Infective Endocarditis (IE), particularly around odontogenic infections and specific dental procedures. The Adult Dental Health Survey in 2009 showed 45% of adults in the UK required dental intervention typically associated with developing IE. Antibiotic prophylaxis in this context is not without controversy. With gum and periodontic disease endemic, is the modern issue one of generalised poor oral health as a risk factor for IE?

Purpose

To determine the impact of oral health on risk and outcome in IE.

Terminology

SDCEP published dental guidelines of when to consider AP against IE for dental procedures. It identifies dental procedures that can cause transient bacteraemia.

Methodology

Data were collected from October 2020-Januaury 2023 in 123 patients with confirmed IE at a central London cardiac surgical centre. Patients had a focussed dental assessment with history, intraoral examination and dental panoramic radiograph to determine the risk and extent of oral disease.

Results

Average age was 54.2years. 77/123 (63%) had native IE (NVE) and 46 (37%) prosthetic (PVE). 17 (37%) cultured oral organisms from blood (Table 1); 8 (47%) of these organisms are associated with active dental disease (decay, periodontal disease, dental infection). Organisms can be found in Table 2.

However, 93/123 (76%) had oral caries requiring dental treatment, irrespective of typical portal of entry for that organism. The proposed dental treatment posed a high risk for causing IE in 70%. 93/123 (76%) needed further dental treatment within six months rendering only 12% of patients orally stable. Oral organisms were seen more frequently in NVE (41/77) vs PVE (17/46). There was no difference in the incidence of dental disease requiring treatment (77% NVE vs 74% PVE). Whilst 27% of PVE had had recent (within 4 months) dental treatment compared to 73% NVE, only 1 PVE patient grew an oral commensal compared to 82% of NVE patients.

Conclusion

Prevention of IE is key to reducing the morbidity and mortality of this disease. We see oral commensals causing IE in 47%, with only 12% of this modern IE cohort dentally stable. Despite this, there was no difference in rates of dental disease requiring invasive treatment when stratified by oral vs non-oral organisms. A robust public health strategy is required to reduce the risk of oral disease driving IE.
Founder effect of a pathogenic TNNT2 variant in the northwest of Spain responsible for a non-severe phenotype of hypertrophic cardiomyopathy
Authors: Valverde M , Peteiro-Deben R P D , Maneiro E M , Garcia-Hernandez S G H , Amor-Salamanca A M S , Cardenas-Reyes I C R , Barriales-Villa R B V , Larranaga-Moreira J M L M , Cabrera Argana D C A , Fernandez Fernandez X F F , Gomez Diaz I G D , Perez Barbeito M P B , Cazon Varela L C V , Ortiz Genga M O G , Ochoa J P O
Published: November 2023

Background

Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disorder, with a prevalence between 1/250-500 individuals. The yield of genetic testing for this condition stands at 40%. The most prevalent genes are MYBPC3 and MYH7, with small contributions of other genes, such as TNNT2, TNNI3, TPM1, MYL2 or FHOD3. At our center, we have identified a recurrent variant in TNNT2, p.Asn271Ile, associated with HCM. Most probands came from the northwest of Spain (Galicia), which suggested that they may share a common origin.

Purpose

We aimed to determine whether carriers of the p.Asn271Ile variant in TNNT2 share a common haplotype, in order to estimate the age of the mutation and describe the associated phenotype.

Methods

We analyzed probands who had TNNT2 sequenced by NGS at our center. Enrichment of the variant was observed in the HCM cohort. Eight highly polymorphic microsatellite markers flanking the variant in 18 Galician HCM probands were also analyzed, compromising a region of approximately 7,300 kb. Custom PCR assays were designed, and fragment length analysis was performed by capillary electrophoresis.

Results

TNNT2 p.Asn271Ile was identified in 49/28,802 probands (0.17%). The variant was significantly enriched in HCM probands (47/11,870; 0.39%) compared to internal non-HCM controls (2/14,804; 0.02%), with an OR=29.3 (IC95%=7.1-120.7). The analysis revealed that the 18 HCM Galician probands shared a common haplotype of 500 kb, estimating that p.Asn271Ile has arisen approximately 26.5 generations ago (650 years).

Regarding genotype-phenotype correlation, our data (more than 180 carriers from 64 families) shows a relatively benign behavior, with an advance mean age at diagnosis [(49.8 (±17.7)], non-severe left ventricular hypertrophy [15.3 (±5.3)], and a lower rate of major events among carriers of p.Asn271Ile in TNNT2, compared to both other genetic variants in TNNT2 and the main genetic cause of HCM (i.e., null variants in MYBPC3) (p=0.0001 for both comparisons). The prevalence of left ventricular systolic dysfunction and left ventricular tract obstruction was also smaller than that described for other sarcomeric genes (3.54% and 12%, respectively).

Conclusions

A founder effect of the pathogenic variant p.Asn271Ile has been demonstrated, with the variant arising approximately 650 years ago. The clinical behavior in carriers of this cohort showed to be relatively benign compared to the behavior of other genetic variants in this gene and null variants in MYBPC3.
Increased troponin I blood level and in-hospital outcome across successive COVID-19 waves
Authors: Benchimol Barbosa P R
Published: November 2023

Introduction

Troponin I blood level (TnI) is often elevated in patients hospitalized due to COVID-19, and high TnI is associated with adverse outcomes, in this scenario. However, the case rate of high TnI in hospitalized patients and respective case fatality rates (CFR) across different COVID-19 waves still demand investigation, as emerging SARS-CoV-2 variants may affect the cardiac tissue diversely. This study investigated the case rate of high TnI and respective in-hospital outcome in patients hospitalized due to COVID-19 during successive pandemic waves.

Methods

In a retrospective observational cohort study, patients hospitalized due to COVID-19 from March 1st 2020 to July 31st 2022 in a reference hospital were analyzed. Inclusion criteria were: positive SARS-CoV-2 RT-PCR, hospitalization in a COVID-19 cohort ward or ICU, and at least one TnI assessed during hospitalization. Patients presenting acute coronary syndromes were excluded. TnI was assessed using electrochemiluminescence technique, and the highest value during hospital stay considered for analysis. TnI was positive (+) if above normality reference level and negative (-), otherwise. Outcome was in-hospital survival. Age on admission, total length-of-stay (TLOS), TnI(+) case rate, and CFR (the rate of non-survivors to COVID-19 admissions) were analyzed. COVID-19 waves were analyzed on 7-day moving average positive cases series (1), and respective onset and offset assessed by change point detection algorithm and visual inspection. In each wave period, dominants circulating variants from surveillance data (2,3) were matched. Discrete variables were described as percentage and analyzed by Chi-squared test. Continuous variables were described as mean ± SD, and compared by Student t or 1-factor ANOVA test as appropriate. Bicaudal 95% confidence interval (CI) was calculated as needed. Alpha error level was set at 0.05.

Results

From March 1st 2020 to July 31st 2022, six COVID-16 waves were identified, and 628 patients met the inclusion criteria. Overall, TnI(+) case rate was 72.0% (95% CI [68.4% - 75.4%]), and CFR was higher among TnI(+) (63.7%) than TnI(-) (32.4%; p < 0.001). As of March 1st 2020, there was a significant trend toward increasing TnI(+) case rate (p trend < 0.001) and decreasing CFR in both TnI(+) (p trend < 0.001) and TnI(-) (p trend < 0.01) across successive COVID-19 waves. Patients with TnI(+) were older (66.1 ± 14.7 years old) and had a longer TLOS (27.8 ± 24.5 days) than with TnI(-) (respectively, 59.0 ± 15.7 years old and 20.6 ± 17.0 days; p < 0.001 for both). TnI(+) case rate, TnI(+)-related and TnI(-)-related CFR, age, and TLOS across COVID-19 waves are in Table 1.

Conclusion

From March 1st 2020 to July 31st 2022, in patients hospitalized due to COVID-19, TnI(+) was associated with increased case fatality rate as compared to TnI(-), across six successive COVID-19 waves. Patients presenting TnI(+) were older and had longer total length-of-stay as compared to TnI(-).Table 1