[Endocarditis caused by Propionibacterium acnes -- a diagnostic and therapeutic challenge]. / Endokarditis verursacht durch Propionibacterium acnes - eine diagnostische und therapeutische Herausforderung.

HISTORY AND ADMISSION FINDINGS: A 77-year-old man suffered from recurrent peripheral cerebral embolisms five months after aortic valve replacement with a bioprosthesis (SJM Epic 25 mm). INVESTIGATIONS: MRT scanning of the brain revealed multiple ischemic areas in different vascular territories. Clinical signs of infective endocarditis were missing and markers of infection were only modestly increased. However, transthoracic echocardiography showed elevated pressure gradients across the bioprosthesis. Transesophageal echocardiography detected multiple vegetations suggestive of infective endocarditis. Several anaerobic blood cultures grew Propionibacterium acnes. DIAGNOSIS, TREATMENT AND COURSE: Infective endocarditis affecting the aortic bioprosthesis and aortic root abscess due to Propionibacterium acnes was diagnosed. During parenteral antibiotic treatment with Amicillin/Sulbactam and Gentamicin full remission developed. Four months later a follow-up transesophageal echocardiography showed a relapse. This time the patient was treated intravenously with penicillin and gentamicin and underwent surgical treatment. CONCLUSION: Cardioembolic events should raise suspicion of infective endocarditis, even if typical clinical signs are absent. Propionibacterium acnes is often grown from blood cultures as a contaminant. Nonetheless, Propionibacterium acnes was the cause of the infective endocarditis. In case of conservative management, close intervals of follow-up transesphageal echocardiography are of importance.

The Residual Platelet Aggregation after Deployment of Intracoronary Stent (PREDICT) score.

BACKGROUND: Recent studies suggest a high interindividual variability of response to clopidogrel associated with adverse cardiovascular outcome. Different clinical factors are considered to influence a persistent residual platelet aggregation (RPA) despite conventional antiplatelet therapy. OBJECTIVES: To investigate clinical factors that affect RPA after 600-mg clopidogrel loading in a large unselected cohort of patients with symptomatic CAD. METHODS: The study population included a consecutive cohort of 1,092 patients treated with coronary stenting for stable angina and acute coronary syndromes (ACS). Residual platelet activity was assessed by ADP (20 micromol L(-1))-induced platelet aggregation >or= 6 h after LD. Eleven clinical factors were included in the primary analysis. RESULTS: In multivariate regression analysis increased RPA was significantly influenced by ACS, reduced LV-function, diabetes mellitus, renal failure (creatinine > 1.5 mg dL(-1)), and age > 65 years. In a factor-weighed model the risk for high RPA increased with higher score levels (OR for patients with a score of 1-3, 1.21, 95% CI 0.7-2.1; score 4-6, OR 2.0, 95% CI 1.17-3.5; P = 0.01; score 7-9, OR 3.3, 95% CI 1.8-6.0). During a 30-day follow-up the incidence of major adverse events was higher in patients with RPA in the upper tertile (4.8% vs. 2.5% in the 2nd and 1.5% in the 1st tertile; P < 0.05). CONCLUSIONS: The PREDICT score provides a good tool to estimate residual platelet activity after clopidogrel LD by easily available patient details. Additionally, we demonstrate its association with short-term outcome. Thus, patients with a high score may benefit from intensified antiplatelet therapy by improved platelet inhibition and risk reduction for thromboischemic events.

Image quality and diagnostic accuracy of non-invasive coronary imaging with 16 detector slice spiral computed tomography with 188 ms temporal resolution.

OBJECTIVE: To evaluate image quality and clinical accuracy in detecting coronary artery lesions with a new multidetector spiral computed tomography (MDCT) generation with 16 detector slices and a temporal resolution of 188 ms. METHODS: 124 consecutive patients scheduled for invasive coronary angiography (ICA) were additionally studied by MDCT (Sensation 16 Speed 4D). MDCTs were analysed with regard to image quality and presence of coronary artery lesions. The results were compared with ICA. RESULTS: 120 of 124 scans were successful. The image quality of all remaining 120 scans was sufficient (mean (SD) heart rate 64.2 (9.8) beats/min, range 43-95). The mean calcium mass was 167 (223) mg (range 0-1038). Thirteen coronary segments were evaluated for each patient (1560 segments in total). Image quality was graded as follows: excellent, 422 (27.1%) segments; good, 540 (34.6%) segments; moderate, 277 (17.7%) segments; heavily calcified, 215 (13.8%) segments; and blurred, 106 (6.8%) segments. ICA detected 359 lesions with a diameter stenosis > 50% and MDCT detected 304 of 359 (85%). Sensitivity, specificity, and positive and negative predictive values were 85%, 98%, 91%, and 96%, respectively. The correct clinical diagnosis (presence or absence of at least one stenosis > 50%) was obtained for 110 of 120 (92%) patients. CONCLUSIONS: MDCT image quality can be further improved with 16 slices and faster gantry rotation time. These results in an unselected population underline the potential of MDCT to become a non-invasive diagnostic alternative, especially for the exclusion of coronary artery disease, in the near future.