The Role of Echocardiography and Cardiac Computed Tomography in Diagnosis of Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) is a rare disease with a high mortality rate and rising incidence, requiring timely and precise diagnosis in order to choose appropriate therapy. Imaging of morphologic lesions is an integrative part of diagnosis. Artifacts and the patient's habitus make echocardiography difficult to visualize advanced-form IE. Cardiac computed tomography (CCT) constantly shows an additive diagnostic value due to high resolution of cardiac anatomy. Conjecturally, joint application of both diagnostic tests improves overall sensitivity and specificity in diagnosing IE. METHODS: Patients with definite IE underwent transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and CCT. We analyzed valvular and paravalvular IE lesions in all three imaging methods and compared them to surgical or autopsy findings. We calculated sensitivity, specificity, diagnostic accuracy, and positive and negative predictive value of both imaging tests individually and jointly used. RESULTS: We examined 78 patients, male to female ratio 2:1, mean age 52.29 ± 16.62. We analyzed 85 valves, 70 native valves, 13 prosthetic valves, and 2 corrected valves due to Ozaki procedure, along with a central shunt and 4 pacemaker leads. As a single test, the sensitivity and specificity of CCT, TTE, and TEE for valvular lesions were 91.6/20%, 65.5/57.9%, and 60/84%, and paravalvular lesions were 100/0%, 46/10.5%, and 14.7/100%. When combined together, sensitivity and specificity for valvular lesions rose to 96.6/0% and paravalvular lesions to 100/0%. We also analyzed the diagnostic performance for each test in single and mutual application, per specific IE lesion. CONCLUSION: In the individual application, CCT in comparison to TTE and TEE shows better diagnostic performance in detection of valvular and paravalvular lesions. In joint application, there is a statistically significant difference in performance compared to their single use, especially in prosthetic valves and invasive forms of IE native valves.

Cardiac pacemaker-related endocarditis complicated with pulmonary embolism: Case report.

Cardiac device-related endocarditis as a device-therapy complication is a growing problem due to higher life expectancy and the increasing number of abandoned leads and subclinical symptoms. We reported a case of a 47-year-old woman with an implanted pacemaker who was admitted to the clinic for cardiology due to the right-sided device-related infective endocarditis of the pacemaker leads with vegetations, predominantly in the right atrium and right ventricle and complicated by pulmonary embolism. Several years after pacemaker implantation, she was diagnosed with systemic lupus erythematosus and started immunosuppressive therapy. The patient was treated with prolonged intravenous antibiotic therapy. The atrial and ventricular lead was extirpated, and the posterior leaflet of the tricuspid valve was shaved.

Cardiac device-related infective endocarditis need for lead extraction whatever the device according to the ESC EORP EURO-ENDO registry.

Aims: Cardiac device-related infective endocarditis (CDRIE) is a severe complication of cardiac device (CD) implantation and is usually treated by antibiotic therapy and percutaneous device extraction. Few studies report the management and prognosis of CDRIE in real life. In particular, the rate of device extraction in clinical practice and the management of patients with left heart infective endocarditis (LHIE) and an apparently non-infected CD (LHIE+CDRIE-) are not well described. Methods and results: We sought to study in EURO-ENDO, the characteristics, prognosis, and management of 483 patients with a CD included in the European Society of Cardiology EurObservational Research Programme EURO-ENDO registry. Three populations were compared: 280 isolated CDRIE (66.7 ± 14.3 years), 157 patients with LHIE and an apparently non-infected CD (LHIE+CDRIE-) (71.1 ± 13.6), and 46 patients with both LHIE and CDRIE (LHIE+CDRIE+) (70.2 ± 10.1). Echocardiography was not always transoesophageal echography (TOE); it was transthoracic echography (TTE) for isolated CDRIE in 88.4% (TOE = 67.6%), for LHIE+CDRIE- TTE = 93.0% (TOE = 58.6%), and for CDRIE+LHIE+ TTE = 87.0% (TOE = 63.0%). Nuclear imaging was performed in 135 patients (positive for 75.6%). In-hospital mortality was lower in isolated CDRIE 13.2% vs. 22.3% and 30.4% for LHIE+CDRIE- and LHIE+CDRIE+ (P = 0004). Device extraction was performed in 62.1% patients with isolated CDRIE, 10.2% of LHIE+CDRIE- patients, and 45.7% of CDRIE+LHIE+ patients. Device extraction was associated with a better prognosis [hazard ratio 0.59 (0.40-0.87), P = 0.0068] even in the LHIE+CDRIE- group (P = 0.047). Conclusion: Prognosis of endocarditis in patients with a CD remains poor, particularly in the presence of an associated LHIE. Although recommended by guidelines, device extraction is not always performed. Device removal was associated with better prognosis, even in the LHIE+CDRIE- group.

The basic heart anatomy and physiology from the cardiologist's perspective: Toward a better understanding of left ventricular mechanics, systolic, and diastolic function.

A comprehensive understanding of the cardiac structure-function relationship is essential for proper clinical cardiac imaging. This review summarizes the basic heart anatomy and physiology from the perspective of a heart imager focused on myocardial mechanics. The main issues analyzed are the left ventricular (LV) architecture, the LV myocardial deformation through the cardiac cycle, the LV diastolic function basic parameters and the basic parameters of the LV deformation used in clinical practice for the LV function assessment.

The role of imaging in infective endocarditis.

Infective endocarditis (IE) poses a large diagnostic and therapeutical challenge. An early diagnosis is necessary for a positive outcome. Echocardiography is initial diagnostic method when there is a possibility of IE presence. TTE and TEE are useful in detection, accurate localisation and estimation of vegetation size, and also in detection of paravalvular spreading of infection. In certain situations, there is a need for usage of complementary methods like CCT and nuclear techniques. This article will outline advantages and limitations of certain diagnostic methods in diagnosis of IE.

Multimodality imaging for the management of patients with primary mitral regurgitation.

Advanced cardiac imaging (ACI), including myocardial deformation imaging, 3D echocardiography and cardiac magnetic resonance, overcomes the limitations of conventional echocardiography in the assessment of patients with primary mitral regurgitation (MR). They enable a more precise MR quantification and reveal early changes before advanced and irreversible remodeling with depressed heart function occurs. ACI permits a thorough analysis of mitral valvular anatomy and MR mechanisms (important for planning and guiding percutaneous and surgical procedures) and helps to identify structural and functional changes coupled with a high arrhythmogenic potential, especially the occurrence of atrial fibrillation and heart failure development. The key question is how the data provided by ACI can improve the current management of primary MR.

Role of different echocardiographic modalities in the assessment of microvascular function in women with ischemia and no obstructive coronary arteries.

This review summarizes current knowledge about echocardiographic modalities used to assess microvascular function and left ventricular (LV) systolic function in women with ischemia and no obstructive coronary arteries (INOCA). Although the entire pathophysiological background of this clinical entity still remains elusive, it is primarily linked to microvascular dysfunction which can be assessed by coronary flow velocity reserve. Subtle impairments of LV systolic function in women with INOCA are difficult to assess by interpretation of wall motion abnormalities. LV longitudinal function impairment is considered to be an early marker of subclinical systolic dysfunction and can be assessed by global longitudinal strain quantification.

The prognostic importance of right ventricular remodeling and the circadian blood pressure pattern on the long-term cardiovascular outcome.

OBJECTIVE: We sought to investigate the predictive value of right ventricular (RV) remodeling and 24-h blood pressure (BP) patterns on long-term cardiovascular prognosis in the initially untreated hypertensive patients. METHODS: The current study included 505 initially untreated hypertensive patients who were consequently included in this study from 2007 to 2012. All the patients underwent laboratory analysis, 24-h BP monitoring and echocardiographic examination at baseline. The patients were followed for a median period of 9 years. The adverse outcome was defined as the hospitalization due to cardiovascular events (atrial fibrillation, myocardial infarction, myocardial revascularization, heart failure, stroke, or cardiovascular death). RESULTS: During the 9-year follow-up period adverse cardiovascular events occurred in 82 hypertensive patients. Night-time SBP, the nondipping BP pattern, left ventricle hypertrophy, RV hypertrophy, right atrial enlargement, RV diastolic dysfunction, and RV systolic dysfunction were associated with adverse cardiovascular events. Nevertheless, night-time SBP, the nondipping BP pattern, mitral E/e', left ventricle hypertrophy, and RV hypertrophy were the only independent predictors of cardiovascular events. When all four BP patterns were included in the model, only the reverse dipping BP pattern was an independent predictor of cardiovascular events. CONCLUSION: The present investigation showed that RV hypertrophy and the reverse dipping BP pattern were independent long-term predictors of the cardiovascular outcome. Detailed echocardiographic evaluation and 24-h ambulatory blood pressure monitoring should be performed even in low-risk hypertensive patients.

The Prognostic Effect of Circadian Blood Pressure Pattern on Long-Term Cardiovascular Outcome is Independent of Left Ventricular Remodeling.

We aimed to investigate the predictive value of 24 h blood pressure (BP) patterns on adverse cardiovascular (CV) outcome in the initially untreated hypertensive patients during long-term follow-up. This study included 533 initially untreated hypertensive patients who were involved in this study in the period between 2007 and 2012. All participants underwent laboratory analysis, 24 h BP monitoring, and echocardiographic examination at baseline. The patients were followed for a median period of nine years. The adverse outcome was defined as the hospitalization due to CV events (atrial fibrillation, myocardial infarction, myocardial revascularization, heart failure, stroke, or CV death). During the nine-year follow-up period, adverse CV events occurred in 85 hypertensive patients. Nighttime SBP, non-dipping BP pattern, LV hypertrophy (LVH), left atrial enlargement (LAE), and LV diastolic dysfunction (LV DD) were risk factors for occurrence of CV events. However, nighttime SBP, non-dipping BP pattern, LVH, and LV DD were the only independent predictors of CV events. When all four BP pattern were included in the model, non-dipping and reverse dipping BP patterns were associated with CV events, but only reverse-dipping BP pattern was independent predictor of CV events. The current study showed that reverse-dipping BP pattern was predictor of adverse CV events independently of nighttime SBP and LV remodeling during long-term follow-up. The assessment of BP patterns has very important role in the long-time prediction in hypertensive population.

Right ventricular mechanics in patients with aortic stenosis and preserved ejection fraction: Is arterial hypertension a new player in the game?

The purpose of this investigation was to evaluate the influence of aortic stenosis (AS) on right ventricular (RV) strain and particularly the importance of arterial hypertension on this association. This cross-sectional study included 107 patients with moderate and severe AS (with and without hypertension) and preserved left ventricular ejection fraction (>50%) and 82 age-matched normotensive and hypertensive controls who underwent comprehensive echocardiographic examination. AS patients were divided into normotensive and hypertensive groups. Left ventricle (LV) mass index gradually increased from the controls, across the moderate AS to the severe AS. There was a trend of reduction of RV global and layer-specific longitudinal strain of the whole ventricle and RV free wall from the controls, across the moderate AS to the severe AS. RV global longitudinal strain, as well as layer-specific RV longitudinal strains, was significantly lower in the patients with severe AS than the controls and the normotensive patients with moderate AS. Endocardial and epicardial RV strains were lower in hypertensive than in normotensive patients with moderate AS. In patients with severe AS, there was no difference between normotensive and hypertensive patients. LV mass index and mean aortic valve gradient were associated with RV global longitudinal strain in AS patients independently of systolic blood pressure, LV ejection fraction (EF), age, and body mass index (BMI). In conclusion, RV mechanics was deteriorated in the patients with moderate and severe AS. There was a trend of RV longitudinal strain worsening in the hypertensive patients with AS in comparison with their normotensive counterparts. Severity of AS, expressed by the mean AV gradient, was related with RV longitudinal strain.

The impact of arterial hypertension on left ventricular strain in patients with aortic stenosis and preserved ejection fraction.

OBJECTIVE: The influence of arterial hypertension on aortic stenosis severity is still controversial. The aim of this study was to evaluate the influence of hypertension on LV strain in patients with moderate and severe aortic stenosis. METHODS: This cross-sectional study included 115 patients with moderate and severe aortic stenosis and preserved LV ejection fraction (>50%) and 89 age-matched normotensive and hypertensive controls who underwent comprehensive echocardiographic examination. Aortic stenosis patients were divided into normotensive and hypertensive groups. RESULTS: There was no significant difference in LV ejection fraction between hypertensive and normotensive aortic stenosis patients. LV mass index gradually increased with the grade of aortic stenosis. LV global longitudinal strain, as well as endocardial and epicardial longitudinal strains, was significantly lower in hypertensive patients with severe aortic stenosis than in their normotensive counterparts. There was no significant difference in LV global circumferential strain between normotensive and hypertensive patients with severe aortic stenosis. Among patients with moderate aortic stenosis, there was no difference in global longitudinal strain between normotensives and hypertensive patients, whereas circumferential was significantly lower in hypertensive patients. LV radial strain was reduced in patients with severe aortic stenosis than in control subjects. SBP and mean aortic valve gradient were associated with LV global longitudinal and circumferential strains in aortic stenosis patients independently of LV mass index, LVEF, age and BMI. CONCLUSION: Hypertension had additional significant negative influence on LV mechanics in patients with significant aortic stenosis. Blood pressure was associated with LV global longitudinal and circumferential strains in aortic stenosis patients independently of main clinical and demographic characteristics.

The influence of sex on left ventricular strain in hypertensive population.

OBJECTIVE: The aim of this study was to evaluate the influence of sex on left ventricular mechanics in hypertensive individuals. METHODS: This cross-sectional study included 171 untreated hypertensive patients and 112 normotensive controls who underwent a 24-h ambulatory blood pressure monitoring and comprehensive echocardiographic examination including strain assessment. RESULTS: Hypertensive women and men had significantly lower left ventricular global longitudinal and circumferential strains than their normotensive counterparts. Left ventricular global longitudinal strain was lower in hypertensive men than in women (-19.8 ±â€Š2.2 vs. -17.9 ±â€Š2.1%; P < 0.01). Left ventricular global circumferential strain was also reduced in hypertensive men in comparison with women (-21.0 ±â€Š2.5 vs. -18.7 ±â€Š2.3%; P < 0.01). The difference in left ventricular radial strain was not discovered between hypertensive women and men. Furthermore, left ventricular twist was significantly higher in hypertensive women than in hypertensive men (21.9 ±â€Š4.1° vs. 20.6 ±â€Š3.8°; P = 0.034). Female sex and arterial hypertension, and also their interaction, were associated with lower left ventricular mass index, increased left ventricular global longitudinal, and circumferential strains and increased left ventricular twist compared with hypertensive men. CONCLUSION: Left ventricular longitudinal and circumferential strains were significantly reduced in hypertensive patients. However, the changes are more pronounced in hypertensive men than in women. Sex has a significant effect on the association between hypertension, and longitudinal and circumferential strain.

Prosthetic valve endocarditis - A trouble or a challenge?

Prosthetic valve endocarditis (PVE) represents a rare and serious complication of valve replacement associated with high morbidity and mortality, which significantly differs from native valve endocarditis (NVE). There are two major problems: establishing diagnosis and treatment of PVE. Diagnosis in PVE is challenging and often requires several imaging methods besides standard microbiological analyzes. Transesophageal echocardiographic examination remains the widely used imaging technique in PVE diagnosis, but additional techniques such as computed tomography (CT) and 18F-fluodeoxyglucose positron emission tomography/CT are often necessary. Persistent fever, embolic complications, valve dehiscence, intracardial abscess, heart failure, as well as staphylococcal and fungal PVE require surgical treatment to avoid lethal outcome. The introduction of transcatheter valve implantations and devices significantly complicated the approach - diagnostic and therapeutic to PVE patients. Despite constantly increasing knowledge regarding pathogenesis and treatment of PVE, the optimal therapy remains a matter of debate. Additional studies are necessary to define therapeutic strategies for this potentially fatal complication.

Gender-specific therapeutic approach in arterial hypertension - Challenges ahead.

Hypertension was thought to be more important cardiovascular risk factor in men than in women. However, studies showed that overall incidence of hypertension-related cardiovascular diseases is higher in women comparing with men and this is particularly valid in menopause when prevalence of hypertension and its complications sharply and suddenly rises. It was also noticed that the effect of various antihypertensive groups was different in women and men. Some medications are prescribed more often in women, but it does not necessary mean that these drugs are more effective in this gender. There are several important reasons that could explain gender-induced differences in blood pressure levels, blood pressure control and antihypertensive treatment. They involve sex hormones, the renin-angiotensin-aldosterone and sympathetic nervous system, and arterial stiffness. However, taking into account many observational studies and trials, there are no consistent data regarding the impact of gender on effect of antihypertensive medications. Longitudinal study focused on gender and current antihypertensive groups would significantly help to understand the impact of gender. This might change therapeutic approach and improve cost-effectiveness in antihypertensive therapy in both genders. A full understanding of the pathophysiological characteristics of variations between genders demands additional research. This review article summarized the current knowledge regarding differences in the prevalence and awareness of arterial hypertension in women and men; alterations in pathophysiological mechanisms of hypertension between sexes; as well as the impact of sex on the effects of main antihypertensive groups of medications.

Does gender affect the association between right ventricular strain and arterial hypertension?

The importance of right ventricular (RV) structure and function in cardiovascular and total morbidity and mortality has been confirmed previously. The purpose of this study was to evaluate the influence of gender on RV structure and function in untreated hypertensive patients. This cross-sectional study included 243 subjects who underwent 24-hour ambulatory blood pressure (BP) monitoring and comprehensive echocardiographic examination including strain evaluation. There was no difference in RV diameter between hypertensive and normotensive women and men. RV wall thickness, right atrial volume index (RAVI), and tricuspid E/e' ratio were significantly higher in hypertensive women and men than in their normotensive counterparts. RV global longitudinal and RV free wall longitudinal strains were significantly lower in hypertensive women and men than in their normotensive counterparts. Arterial hypertension affected RV wall thickness, RAVI, tricuspid E/e', and RV longitudinal strain. Gender affected RV diameter, RAVI, tricuspid E/e', and RV longitudinal strain, whereas hypertension-gender interaction affected RAVI, E/e', and RV longitudinal strain. The 24-hour systolic BP and LV mass index were independently associated with RV free wall longitudinal strain. RV wall thickness was independently associated with RV free wall longitudinal strain only in women, and tricuspid E/e' was independently associated only in men. In conclusion, RV longitudinal strain was significantly decreased in hypertensive patients in both sexes. Hypertensive men suffered more evident RV mechanical changes than hypertensive women. Gender, arterial hypertension, and their interaction had the important role in RV structural and mechanical remodeling.

Three-Year Impact of Immediate Invasive Strategy in Patients With Non-ST-Segment Elevation Myocardial Infarction (from the RIDDLE-NSTEMI Study).

Previous studies compared clinical outcomes of early versus delayed invasive strategy in patients with non-ST-elevation acute coronary syndrome up to 1-year follow-up, but long-term data remain scarce. Our aim was to evaluate the long-term effects of immediate invasive intervention in patients with Non-ST-Segment Elevation Myocardial Infarction (NSTEMI). The Randomized Study of Immediate Versus Delayed Invasive Intervention in Patients With Non-ST-Segment Elevation Myocardial Infarction (RIDDLE-NSTEMI) was a randomized, investigator-initiated, parallel-group trial that assigned 323 patients with NSTEMI (1:1) to either immediate (median time to intervention 1.4 hours) or delayed invasive strategy (61.0 hours). The primary end point was the composite of death or new myocardial infarction (MI). At 3 years, immediate invasive intervention was associated with a lower rate of death or new MI, compared with a delayed invasive strategy (12.3% vs 22.5%, hazard ratio 0.50, 95% confidence interval 0.29 to 0.87, p = 0.014). The observed benefit of immediate intervention was mainly driven by an increased early reinfarction risk in delayed strategy, with similar new MI rates beyond 30 days (4.4% in the immediate and 5.6% in the delayed group, p = 0.61). Three-year mortality was 9.3% in the immediate invasive strategy, and 10.0% in the delayed strategy (p = 0.83). High baseline Global Registry of Acute Coronary Events score (>140) was associated with a significant increase in long-term mortality, regardless of the timing of invasive intervention. In conclusion, whereas immediate invasive intervention significantly reduced the early risk of new MI, the timing of invasive intervention appears to have no significant impact on clinical outcomes beyond 30 days, which seem to mostly be related to the baseline clinical risk profile.