RESUMEN
BACKGROUND: Infective endocarditis (IE) is associated with high rates of mortality. Prolonged treatments with high-dose intravenous antibiotics often fail to eradicate the infection, frequently leading to high-risk surgical intervention. By providing a mechanism of antibiotic tolerance, which escapes conventional antibiotic susceptibility profiling, microbial biofilm represents a key diagnostic and therapeutic challenge for clinicians. This study aims at assessing a rapid biofilm identification assay and a targeted antimicrobial susceptibility profile of biofilm-growing bacteria in patients with IE, which were unresponsive to antibiotic therapy. RESULTS: Staphylococcus aureus was the most common isolate (50%), followed by Enterococcus faecalis (25%) and Streptococcus gallolyticus (25%). All microbial isolates were found to be capable of producing large, structured biofilms in vitro. As expected, antibiotic treatment either administered on the basis of antibiogram or chosen empirically among those considered first-line antibiotics for IE, including ceftriaxone, daptomycin, tigecycline and vancomycin, was not effective at eradicating biofilm-growing bacteria. Conversely, antimicrobial susceptibility profile of biofilm-growing bacteria indicated that teicoplanin, oxacillin and fusidic acid were most effective against S. aureus biofilm, while ampicillin was the most active against S. gallolyticus and E. faecalis biofilm, respectively. CONCLUSIONS: This study indicates that biofilm-producing bacteria, from surgically treated IE, display a high tolerance to antibiotics, which is undetected by conventional antibiograms. The rapid identification and antimicrobial tolerance profiling of biofilm-growing bacteria in IE can provide key information for both antimicrobial therapy and prevention strategies.
Asunto(s)
Antibacterianos/farmacología , Bacterias/clasificación , Bacterias/efectos de los fármacos , Biopelículas/efectos de los fármacos , Endocarditis Bacteriana/diagnóstico , Endocarditis/microbiología , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Bacterias/aislamiento & purificación , Farmacorresistencia Bacteriana Múltiple , Endocarditis/tratamiento farmacológico , Endocarditis/cirugía , Endocarditis Bacteriana/tratamiento farmacológico , Endocarditis Bacteriana/cirugía , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Filogenia , Resultado del TratamientoRESUMEN
AIMS: To compare early and late mortality of acute isolated tricuspid valve infective endocarditis (TVIE) treated with valve repair or replacement. METHODS: Patients who were surgically treated for TVIE from 1983 to 2018 were retrieved from the Italian Registry for Surgical Treatment of Valve and Prosthesis Infective Endocarditis. All the patients were followed up by means of phone interview or calling patient referral physicians or cardiologists. Kaplan-Meier method was used to assess late survival and survival free from TVIE recurrence with log-rank test for univariate comparison. The primary end points were early mortality (30âdays after surgery) and long-term survival free from TVIE recurrence. RESULTS: A total of 4084 patients were included in the registry. Among them, 149 patients were included in the study. Overall, 77 (51.7%) underwent TV repair and 72 (48.3%) TV replacement. Early mortality was 9% (13 patients). Expected early mortality according to EndoSCORE was 12%. The TV repair showed lower mortality and major complication rate (7% and 16%), compared with TV replacement (11% and 25%), but statistical significance was not reached. Median follow-up was 19.1âyears (14.3-23.8). Late deaths were 30 and IE recurrences were 5. No difference in cardiac survival free from IE was found between the two groups after 20âyears (80â±â6% Repair Group vs 59â±â13% Replacement Group, P = 0.3). CONCLUSIONS: Overall results indicate that once surgically addressed, TVIE has a low recurrence rate and excellent survival, apparently regardless of the type of surgery used to treat it.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Endocarditis Bacteriana , Endocarditis , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Endocarditis/cirugía , Endocarditis Bacteriana/cirugía , Humanos , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugíaRESUMEN
BACKGROUND: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry. METHODS: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47⯱â¯16â¯years (range 15-86â¯years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival. RESULTS: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (nâ¯=â¯17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25â¯years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs. CONCLUSIONS: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25â¯years.
Asunto(s)
Endocarditis/cirugía , Enfermedades de las Válvulas Cardíacas/microbiología , Enfermedades de las Válvulas Cardíacas/cirugía , Válvula Tricúspide/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Italia , Masculino , Persona de Mediana Edad , Sistema de Registros , Factores de Tiempo , Insuficiencia de la Válvula Tricúspide/complicaciones , Insuficiencia de la Válvula Tricúspide/cirugía , Adulto JovenRESUMEN
BACKGROUND: In 2015 a new device for the collection of mediastinal fluid from patients with deep sternal wound infection (DSWI) in the presence of negative-pressure wound therapy (NPWT) became available. The present study was designed to evaluate whether changing sample collection devices increased micro-organism detection in patients undergoing NPWT. METHODS: During 2013-2014, 207 samples were collected and cultured from NPWT patients (n = 23) to demonstrate the presence of DSWI using reticulated polyurethane sponge culture, a swab, and blood culture. In 2015, a new collection device was introduced for specimen collection. A total of 357 samples (n = 17) were collected using the ESwab(™) (Copan, Murrieta, CA) for deep and superficial wound sample collection. In addition, blood culture devices were used for collecting mediastinal fluid aspirated directly from the wound and biologic fluid obtained from the NPWT device. Fisher exact test was performed to test the rate of independence rate of micro-organism identification using the NPWT sponge device and taking blood culture results as a reference for micro-organism identification. RESULTS: After the introduction of the new collection device in our hospital, an overall increase in the detection of micro-organisms (46.7%) was reported. During 2013-2014 our traditional microbiologic collection method did not detect a pathogen in 30.4% of patients. During 2015, the new sample collection approach, direct from the NPWT device, improved micro-organism detection by 10.4% and reduced DSWIs with undetected pathogens to 17.6% (p < 0.01). CONCLUSIONS: As a result of proficiency gained in the last year, the most representative specimen in wound infection was represented by mediastinal fluid collected directly from the wound and the NPWT device. Given the correlation between the blood culture of micro-organisms detected using the ESwab device from the wound, mediastinal drainage, and drainage from the NPWT device, we can assume that the NPWT device may replace the other biologic sampling devices.
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Terapia de Presión Negativa para Heridas/instrumentación , Terapia de Presión Negativa para Heridas/métodos , Manejo de Especímenes/métodos , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/terapia , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Mediastino/cirugía , Persona de Mediana Edad , Terapia de Presión Negativa para Heridas/estadística & datos numéricos , Esternón/cirugía , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/microbiologíaRESUMEN
This is the first reported case of 2 biofilm-producing bacteria, Staphylococcus aureus and Proteus mirabilis, identified from an aortic valve using an innovative device with dithiothreitol solution, able to dislodge bacterial biofilm. The method is usable in the operating theatre and recommended in infective endocarditis nonresponders to empiric therapy.
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Válvula Aórtica/microbiología , Biopelículas/efectos de los fármacos , Endocarditis Bacteriana/diagnóstico por imagen , Endocarditis Bacteriana/tratamiento farmacológico , Proteus mirabilis/efectos de los fármacos , Staphylococcus aureus/efectos de los fármacos , Adulto , Válvula Aórtica/efectos de los fármacos , Válvula Aórtica/cirugía , Ecocardiografía Transesofágica/métodos , Endocarditis Bacteriana/etiología , Endocarditis Bacteriana/cirugía , Estudios de Seguimiento , Humanos , Masculino , Quirófanos , Proteus mirabilis/fisiología , Medición de Riesgo , Staphylococcus aureus/fisiología , Trastornos Relacionados con Sustancias/complicaciones , Resultado del TratamientoRESUMEN
Despite the efforts that have been made at an international level to identify and control cardiovascular risk factors, cardiopathies and, in particular, coronary artery disease (CAD), remain the principal cause of death in Europe and the United States. These data confirm the importance and necessity of noninvasive, reliable diagnostic imaging of early CAD. Coronary angiography is still the hinge, around which all instrumental and laboratory investigations turn, for cardiac ischaemia today. Indeed, it still holds the role of "gold standard" for the study of the coronary arterial lumina, particularly the smaller vessels due to their complex spatial geometry and because of cardiac motion. At present, with the exception of the study of the coronary arterial lumen, MR is a non-invasive examination, already capable of supplying precise global and regional function, the evaluation of the intra-cardiac flow, myocardial perfusion and the overall viability of the heart.
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Imagen por Resonancia Magnética , Isquemia Miocárdica/patología , Angiografía Coronaria , Circulación Coronaria , Humanos , Cinética , Imagen por Resonancia Magnética/métodos , Contracción Miocárdica , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/patología , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/fisiopatología , Miocardio/patología , Tamaño de los Órganos , Reproducibilidad de los ResultadosRESUMEN
Coronary artery bypass grafting (CABG) still plays a fundamental role in the management of acute coronary syndromes. The aim of this study is to report the experience of our center in the treatment of patients with acute coronary sindromes without persistent ST elevation urgently operated on with CABG, and to discuss surgical problems related. Two-hundred and six patients were urgently operated on for CABG for acute coronary syndromes without persistent ST-segment elevation from January 2001 to February 2003. The majority of them had three vessel coronary disease (72%) and left main stem disease occurred in 20% of the patients. Mean LVEF (left ventricular ejection fraction) was 54 +/- 12% whereas 9% of the patients had a LVEF < 40%. Twenty-one patients (10%) received glycoprotein IIb/IIIa receptor inhibitors and 35 (17%) received intravenous heparin therapy before surgery. Mean interval time between the onset of symptoms and surgery was 16 +/- 10 days (range 4-50). In-hospital mortality was 2% (4 patients). Perioperative AMI (acute myocardial infarction) occurred in 4% (8 patients) and a transient low cardiac output syndrome in 27 patients (13%). Bleeding requiring surgery occurred in 1% of the patients. Transient respiratory insufficiency was present in 12 patients (6%) and acute renal failure in 8 patients (4%). Mean I.C.U. time was 2.4 days (1-17). Urgent CABG for acute coronary syndromes shows a low risk for in-hospital mortality and morbidity. In acute patients arterial grafts are not detrimental for the outcome, but are recommended in the absence of contraindications to improve long-term results. In spite of recent developments in cardioplegic cardiac arrest, optimal myocardial protection against perioperative myocardial infarction still remains a challenge.
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Angina Inestable/fisiopatología , Angina Inestable/cirugía , Puente de Arteria Coronaria , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/cirugía , Enfermedad Aguda , Anciano , Electrocardiografía , Femenino , Humanos , Masculino , SíndromeRESUMEN
Mycotic ascending aortic pseudoaneurysm (AAP) is an uncommon but surgically challenging problem with high morbidity and mortality rates. We describe endovascular repair of an acute mycotic AAP in a high-risk patient. A 45-year old man, HIV serum positive, chronic hepatitis HBV and HCV related, presented, after two sternotomies, with a fast growing 11 6 cm AAP that was sealed with two Gore Exluder aortic cuffs, inserted from the left axillary artery. Nine months control CT continued to show no endoleak with shrinking of the AAP.
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Aneurisma Falso/cirugía , Aneurisma Infectado/cirugía , Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/microbiología , Aneurisma Infectado/diagnóstico por imagen , Aneurisma Infectado/microbiología , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/microbiología , Aortografía/métodos , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
We evaluated histologic results for surgical left maze with an high-intensity focused ultrasound (HIFU) energy source. Two patients came to our attention 6 and 48 months, respectively, after ablation concomitant to a valve procedure. Tissue specimens, obtained from the lesion site on the mitral isthmus and from the "box lesion" around the pulmonary veins were analyzed histologically. A complete transmural lesion was found in all specimens. Chronic lesions exhibited replacement of the muscular band with connective tissue. The atrial wall maintained normal thickness and vascularization. HIFU ablation represents an acceptable energy source to create transmural lesions on the beating human left atrium.
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Estenosis de la Válvula Aórtica/cirugía , Fibrilación Atrial/cirugía , Atrios Cardíacos/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Complicaciones Posoperatorias/cirugía , Venas Pulmonares/cirugía , Ultrasonografía Intervencional , Anciano , Estenosis de la Válvula Aórtica/patología , Fibrilación Atrial/patología , Terapia Combinada , Comorbilidad , Resultado Fatal , Femenino , Estudios de Seguimiento , Atrios Cardíacos/patología , Ultrasonido Enfocado de Alta Intensidad de Ablación , Humanos , Masculino , Insuficiencia de la Válvula Mitral/patología , Venas Pulmonares/patología , Reoperación , Cicatrización de Heridas/fisiologíaRESUMEN
The aim of this study was to examine perioperative mortality and morbidity and midterm results in patients undergoing coronary bypass graft and mitral valve annuloplasty with advanced dilated cardiomyopathy. Sixty-one patients with ischemic dilated cardiomyopathy underwent coronary artery bypass grafting and mitral valve annuloplasty between January 1998 and December 2003. Patients eligible for revascularization that presented a mild or more severe mitral valve regurgitation at echocardiography (effective regurgitant orifice > 0.2 cm(2)) were considered for annuloplasty with a Cosgrove ring. New York Heart Association class (NYHA) III/IV was present in 40 patients (66%) and Canadian Cardiovascular Society class III-IV in 19 (31%). A previous acute myocardial infarction was reported in 48 patients (79%). The mean number of graft anastomoses was 2.5 +/- 0.7 and the left internal mammary artery was used in 49 patients (80%). In-hospital mortality was 4.9% (3 patients), due to unsuccessful weaning from cardiopulmonary bypass, multiple organ failure, and stroke, respectively. Left ventricle ejection fraction improved from 28.9% +/- 5.2% preoperatively to 35.4% +/- 8.1% at follow-up (P = 0.0001) and a significant reduction in NYHA III/IV was detected: from 40 patients preoperatively (66%) to 14 (31%) at follow-up (P = 0.031). Midterm cardiac-related mortality rate was 3.4%. In our experience combined coronary artery bypass grafting and ring annuloplasty for ischemic dilated cardiomyopathy can be performed with acceptable risks for in-hospital mortality and morbidity. Midterm results show a good survival rate and a durable functional improvement in this subset of patients.