The usefulness of cardiac CT in the diagnosis of perivalvular complications in patients with infective endocarditis.

OBJECTIVES: The aim of the study was to compare the usefulness of cardiac CT to transthoracic (TTE) and transesophageal (TEE) echocardiography in the diagnosis of infective endocarditis (IE) and perivalvular complications using surgical inspection as the gold standard. MATERIAL AND METHODS: Fifty-three consecutive patients (42 men, mean age 58.3 ± 12.5) with IE requiring surgical procedures were enrolled in the study. All patients underwent preoperative TTE, TEE, and CT. The presence of vegetations, perivalvular abscess/pseudoaneurysm, leaflet perforation, inflammatory infiltration, and prosthesis dehiscence was assessed. RESULTS: We analyzed 71 affected valves (58 native, 13 prosthetic). Intraoperative assessment revealed 11 abscesses/pseudoaneurysms. Sensitivity and specificity of echocardiography (TTE + TEE) and CT were 63%, 90% and 81%, 90%, respectively. The combination of CT and echocardiography allowed diagnosing all abscesses/pseudoaneurysms. Inflammatory infiltration was found intraoperatively in 15 patients. Sensitivity and specificity of TEE and CT were 53%, 94% and 46%, 100%, respectively. Intraoperative assessment revealed leaflet perforation in 16 patients. Sensitivity and specificity of TEE and CT were 75%, 79% and 43%, 89%. The sensitivity of the combination of TTE + TEE + CT was 81%. Perivalvular leakage was found in eight patients with a prosthetic valve. Sensitivity and specificity of echocardiography and CT were 100%, 100% and 88%, 100%, respectively. TEE showed higher sensitivity (97%) than CT (89%) in the diagnosis of vegetations. CONCLUSIONS: The combination of TTE, TEE, and CT increased the sensitivity for the detection of valvular and perivalvular complications of IE. KEY POINTS: • CT is a useful modality in the diagnosis of IE and its local complications in addition to echocardiography. • For the detection of abscesses and pseudoaneurysms, CT is superior to echocardiography. Combining these two modalities can increase the sensitivity of diagnosing abscess/pseudoaneurysm up to 100%. • Adding CT to TEE increases the sensitivity for detection of inflammatory infiltrate. CT is not superior to echocardiography in diagnosing vegetations, valvular leaflet perforations, and perivalvular leaks, but it can be a useful tool when echocardiography is indeterminate.

[Central nervous system embolism in the course of infective endocarditis]. / Zatorowosc osrodkowego ukladu nerwowego jako powiklanie infekcyjnego zapalenia wsierdzia.

Despite the progress made in diagnosis and treatment of heart valve diseases, the incidence of infective endocarditis (IE) remains constant. It is still associated with high mortality and high rate of embolic complications, including most dangerous one, i.e. stroke. It has a significant impact on further treatment and qualifications for cardiac surgery. In this paper, the authors discuss the epidemiology, mechanisms of stroke and its impact on the qualifications for cardiac surgery. The authors discuss the problem of clinically silent central nervous system embolism in the course of IE and the usefulness of neuroimaging and markers of central nervous system damage in diagnosis of cerebral embolism.

Postcardiac injury syndrome (part II).

A 58-year-old man had undergone 2-vessel off-pump coronary artery bypass surgery (OPCAB), 1 month before he was admitted into the hospital with cardiac tamponade due to pericarditis. Postcardiac injury syndrome (PCIS) was diagnosed. In spite of receiving anti-inflammatory treatment, the patient developed relapsing PCIS.

Rare complication after mitral valve replacement due to infective endocarditis (Part 2).

A 27-year-old woman who had undergone mitral valve replacement for infective endocarditis developed a significant paravalvular leak. Percutaneous transcatheter obliteration of the defect using an Amplatzer Vascular Plug III was undertaken, with an excellent clinical outcome.

Rare complication after mitral valve replacement due to infective endocarditis.

A 27-year-old woman who had undergone mitral valve replacement for infective endocarditis developed a significant paravalvular leak. Percutaneous transcatheter obliteration of the defect using an Amplatzer Vascular Plug III was undertaken, with an excellent clinical outcome.

Effects of pathogenic factors on prognosis in patients with prosthetic valve endocarditis.

INTRODUCTION: Despite progress in medicine, the prevalence of infective endocarditis (IE) in patients with prosthetic valves (PVE) has not decreased. Positive blood and valve cultures are one of the most important diagnostic criteria of IE. There are no unambiguous data regarding the influence of pathogenic factors on prognosis. AIM: To analyse blood and valve cultures in patients with PVE and assess their impact on the risk of early and late deaths as well as IE relapse. METHODS: The study group consisted of 71 PVE patients. Infective endocarditis was diagnosed based on the Polish Cardiac Society guidelines. Early and late mortality as well as IE relapse were analysed in patients hospitalised between 1988 and 1998. RESULTS: Positive blood cultures were found in 55 (77.5%) patients. Early mortality was 15.5% (11 deaths). Coagulase-negative Staphylococcus infection was an independent risk factor of early death (p=0.02). During long-term follow-up 8 (13.3%) patients died. The risk of late death increased with positive valve culture (p=0.04). Recurrence of IE was diagnosed in 6 (10%) patients. Staphylococcus epidermidis was a risk factor of disease relapse (p=0.03). Six-year survival was 73%. CONCLUSIONS: 1. Coagulase-negative Staphylococcus aetiology increases the risk of early death in patients with PVE. 2. Pathogenic factors did not influence the risk of late death. 3. The risk of late death was increased with positive valve culture with negative blood cultures. 4. Staphylococcus epidermidis aetiology increases the risk of PVE relapse.

Influence of pathogenetic factors on prognosis in patients with native valve infective endocarditis.

INTRODUCTION: Despite improvement in medical care the incidence of infective endocarditis (IE) has not decreased. Positive blood cultures are one of the most important diagnostic criteria of IE. There are no uniform data regarding the influence of pathogenetic factors on prognosis. AIM: To analyse the results of blood and valve cultures in patients with IE of native valves and evaluate their influence on the risk of early and late deaths as well as recurrence of IE. METHODS: The study group consisted of 152 patients with IE of native valves. The IE diagnosis was based on the Duke criteria. Early and late mortality as well as recurrence of IE were analysed in patients hospitalised at the Institute of Cardiology in Warsaw from 1988 to 1998. RESULTS: Positive blood cultures were found in 103 (67.8%) of patients. In-hospital mortality was 5.9% (9 deaths). The incidence of early deaths was significantly lower in surgically treated patients (p=0.01). Late deaths occurred in 23 (16%) patients. Results of blood and valve tissue cultures were not related to mortality. Recurrent IE was observed in 7 (4.9%) patients. Staphylococcus aureus was an independent risk factor for recurrent IE (p=0.04). Six-year survival was 79%. CONCLUSIONS: In patients with native valve infective endocarditis: 1. The risk of early and late death is not related to the results of blood and valve cultures. 2. Staphylococcus aureus aetiology increases the risk of disease recurrence. 3. The risk of early death is significantly lower in patients treated with surgery.

Twenty-Year Experience in the Diagnosis and Treatment of Infective Endocarditis.

AIMS: The aim of this study was to compare the etiology, clinical course, selected diagnostic methods and efficacy of the treatment used in patients with infective endocarditis (IE) in the nineteen eighties and nineties. MATERIAL AND METHODS: The study group comprised 300 patients with infective endocarditis hospitalized in the Institute of Cardiology in Warsaw in the following years: from 1982 to 1987 (150 patients: 75 successive patients with IE on the prosthetic valve and 75 successive patients with IE on the native valve), as well as from 1990 to 2003 (150 patients: 75 successive patients with IE on the prosthetic valve and 75 successive patients with IE on the native valve). RESULTS: In the nineties, immunological symptoms, embolism formation and progressive heart failure were diagnosed decidedly more frequently. Early prosthetic valve endocarditis (PVE) (up to 60 days after operation) occurred significantly more frequently in the eighties. The quantity of negative blood cultures in PVE has not decreased, it is still observed in over 20% of cases. For 20 years the etiology of PVE has remained the same, the dominant pathogen remains Staphylococcus. The frequency of PVE caused by Streptococci has markedly reduced. In both the decades analyzed the etiology of native valve endocarditis (NVE) was similar. In the eighties Streptococcus was predominant. In successive years the number of infections caused by Staphylococci was the same as that caused by Streptococci. CONCLUSIONS: The incidence of early PVE decreased in the nineties. More patients were treated surgically with lesser peri-operative mortality. A lower incidence of infective endocarditis on prosthetic valves caused by streptococci may signify better prophylaxis against infective endocarditis. Infective endocarditis with sterile blood cultures continues to occur frequently.

Aortic valve calcification in 499 consecutive patients referred for computed tomography.

INTRODUCTION: Aortic valve calcification (AVC) is the most common cause of aortic stenosis. The aim of the study was to assess the prevalence of aortic valve, coronary artery and aortic calcifications and to evaluate the correlation between calcification of the aortic valve, coronary arteries and aorta. MATERIAL AND METHODS: The study included 499 patients aged 60 years and over who underwent coronary computed tomography because of chest pain. Beside coronary artery calcium score (CAC), we evaluated AVC and ascending aorta calcifications (AAC). RESULTS: Aortic valve calcification was found in 144 subjects (28.9% of the whole study population). Prevalence of CAC and AAC was higher than AVC and amounted to 73.8% and 54.0%. Prevalence of AVC, CAC and AAC was significantly lower in the group of patients ≤ 70 years than in the group of patients > 70 years of age (p = 0.0002, p < 0.0001, p < 0.0001). Aortic valve calcification was more often observed in men than women (34.7% vs. 25.4%, p = 0.02). Degree of aortic valve calcification was also significantly higher among men than women (median score 4 vs. 0, p = 0.01). Similar observations were true for CAC and AAC, where both prevalence and degree of calcification was higher among men than women. In the whole study population no correlation was noted between AVC and CAC or AAC (p = 0.34, p = 0.85). There was a significant correlation between AAC and CAC (p < 0.0001). CONCLUSIONS: Despite some similarities in pathological mechanism and risk factors, a degenerative defect of the aortic valve could be independent of atheromatous lesions in the coronary arteries and aorta.

[Treatment outcome of prosthetic valve endocarditis]. / Wyniki leczenia infekcyjnego zapalenia wsierdzia na sztucznych zastawkach serca.

BACKGROUND AND AIMS OF THE STUDY: Prosthetic valve endocarditis (PVE) occurred from 1 to 9% of patient after heart valve replacement. The aim of the present study was to assess the long term outcome of the treatment of PVE and to analyze the recurrence of infective endocarditis (IE). MATERIAL: Hospital mortality, recurrence and late survival were analyzed in 59 patients hospitalized in the Institute of Cardiology for PVE between 1988-95. There were 26 females and 33 males with age ranging from 17 to 71 years (mean 48). The onset of PVE was within 60 days from valve replacement in 17 patients and therefore it was considered as early PVE, in 42 patients PVE occurred beyond 60 days from valve replacement was considered as late. METHODS: The criteria of Durack et al. were applied to diagnose PVE. Each patient was classified as having definite PVE, possible PVE, or rejected PVE. The late examinations were performed out-patient in Ist Department of Valvular Heart Disease of Institute of Cardiology. RESULTS: Prosthetic valve replacement in addition to medical treatment was preferred for 34 (58%) of the 59 cases (8 death), whereas 25 (42%) cases were only managed medically (5 death). The overall hospital mortality rate was 22% (13 patients). There were 8 (17%) episodes of recurrence with mean interval of 6 months between both episodes. 6 patients were cured, 2 died. Staphylococcal epidermidis infection was present in 63%. Recurrence of IE due to the same microorganism was in 88% of episodes. During follow up (mean 4 years) 5 late deaths occurred. Actual 4 years survival was 69%. CONCLUSIONS: 1. Mean survival after 4 years was 69%, 2. Total mortality was 31%, 22% hospital, 9% in late observation (decreased from 8% in first 2 years to 1% mean 4 years after cure, 3. Recurrence of IE was observed in 17% of episodes, most cases (88%) were caused by the same bacteria as in the primary infection.

Endovascular treatment of PA pseudoaneurysm caused by Swan-Ganz catheter.

The following case report describes a complication of Swan-Ganz catheterization and its endovascular treatment with a single coil. Application of this particular catheter in the pulmonary artery during cardiac surgery may lead to mechanical perforation and creation of an extravascular sac, which is called a pseudoaneurysm. There are different methods that lead to tamponade or closure of the leakage. Interventional cardiology procedures are nowadays the most appropriate way of treatment of Swan-Ganz catheter induced vascular complications.

Factors affecting long-term survival after aortic valve replacement.

BACKGROUND AND AIM: To evaluate long-term outcomes of surgical aortic valve replacement (AVR) due to significant aortic stenosis (AS) and assess changes in factors affecting survival during a 10-year period in patients referred for surgery from a single centre. METHODS: We evaluated 1143 patients (478 women, 665 men; mean age 61 ± 5 years) treated in the Department of Valvular Heart Disease at the Institute of Cardiology in Warsaw who were referred for AVR due to significant AS in 1998-2008 and survived the surgery and the initial 30-day postoperative period. We assessed long-term survival in relation to preoperative parameters including demographic data (age, gender), clinical variables (New York Heart Association [NYHA] class, presence of a significant coronary artery stenosis, arterial hypertension, reduced left ventricular ejection fraction [LVEF]), and operative parameters (prosthetic valve type: biological vs. mechanical, and the type of the surgery: isolated AVR vs. AVR combined with coronary artery bypass grafting). RESULTS: Ten-year survival was worse in men compared to women (p = 0.001), with the effect of gender gradually decreasing after 3 years of follow-up. Factors affecting long-term survival included age (p = 0.0001) and NYHA class (p = 0.005) in women, and age (p = 0.0001), NYHA class (p = 0.0001), arterial hypertension (p = 0.01), reduced LVEF (p = 0.03), and the presence of significant coronary artery stenoses (p = 0.0001) in men. Evaluation of factors affecting 1-, 3-, 5-, and 7-year survival showed their variability mostly in men. CONCLUSIONS: Long-term surgical outcomes in patients with significant AS are very good, with better survival in women compared to men, although these differences attenuated after 3 years. Factors affecting 10-year survival are different in women and men: a significant effect in women was noted only for age and preoperative NYHA class, while in men for age, NYHA class, hypertension, reduced LVEF, and the presence of significant coronary artery stenoses. During 10-year follow-up, longitudinal changes can be noted in factors affecting survival after AVR.

May dual-source computed tomography angiography replace invasive coronary angiography in the evaluation of patients referred for valvular disease surgery?

BACKGROUND: Coronary computed tomography (CT) angiography is currently the only alternative to invasive angiography in the evaluation of coronary anatomy. In patients referred for valvular or thoracic aortic disease surgery, invasive coronary angiography remains the gold standard required by cardiac surgeons during the preoperative evaluation. According to the current European Society of Cardiology guidelines, evaluation of coronary anatomy is recommended in all patients above 40 years of age, with a history of coronary artery disease (CAD), in postmenopausal women, patients with left ventricular systolic dysfunction, with suspected ischaemic aetiology of mitral regurgitation, and in patients with one or more risk factors for CAD. The possibility to perform coronary CT angiography to exclude CAD before planned non-coronary cardiac surgery was first allowed in the 2010 Report of the American College of Cardiology Foundation Task Force on Expert Consensus. AIM: To evaluate the usefulness of dual-source CT for the evaluation of coronary anatomy in patients before planned cardiac valvular surgery. METHODS: We studied 98 consecutive patients with a haemodynamically significant valvular heart disease and guideline-based indications for coronary angiography to exclude CAD before planned valvular surgery. Exclusion criteria included cardiac arrhythmia (atrial fibrillation, frequent ventricular and supraventricular premature beats), estimated glomerular filtration rate < 60 mL/min/1.73 m(2), allergy to iodine contrast agents, and lack of patient consent. Mean patient age was 58.8 (range 30-78) years. Coronary artery calcium score (CACS) was first determined in all patients. Coronary CT angiography was not performed if CACS was > 1000. In the remaining patients, complete CT evaluation was performed with the administration of a contrast agent. Conventional invasive coronary angiography was subsequently performed in patients with at least one > 50% stenosis, artifacts due to calcifications, or motion artifacts. RESULTS: In 79 (80.6%) patients, CT angiography excluded the presence of a significant coronary artery stenosis without the need for invasive angiography. Conventional coronary angiography was required in 19 (19.4%) patients, including 13 (13.3%) patients with a > 50% stenosis in CT angiography, 2 (2%) patients with calcification artifacts, 1 (1%) patient with motion artifacts, 2 (2%) patients with CACS > 1000 in whom CT angiography was nor performed, and 1 (1%) patient with allergic symptoms during administration of a test dose of the contrast agent. Ultimately, significant CAD was diagnosed in 9 (9.2%) patients in whom coronary artery bypass surgery was also performed. In addition, vascular anomalies were diagnosed with cardiac CT angiography in 5 (5.1%) patients. In 14 patients, CT angiography was also used for previously planned evaluation of a coexisting aortic aneurysm. CONCLUSIONS: Coronary CT angiography may be useful to exclude significant CAD in patients referred for valvular disease surgery.

Transapical aortic valve implantation - a rescue procedure for patients with aortic stenosis and "porcelain aorta".

Surgical aortic valve replacement (AVR) still remains the treatment of choice in symptomatic significant aortic stenosis (AS). Due to technical problems, extensive calcification of the ascending aorta ("porcelain aorta") is an additional risk factor for surgery and transapical aortic valve implantation (TAAVI) is likely to be the only rescue procedure for this group of patients. We describe the case of an 81-year-old woman with severe AS and "porcelain aorta", in whom the only available life-saving intervention was TAAVI.