Clinical Features and Mortality Rate of Infective Endocarditis in Intensive Care Unit: A Large-Scale Study and Literature Review.

BACKGROUND: Large-scale multicentric studies reported that, despite advances in diagnosis, antibiotics, and surgical treatment, infective endocarditis (IE) in-hospital mortality remains high. Most data have been obtained from patients treated in infective disease wards, internal medicine, cardiology, or cardiac surgery departments and are therefore heterogeneous. The few studies focused on complicated IE patients leading to intensive care unit (ICU) admission have reported different methodologies and results. The aim of our study was to describe the epidemiological, clinical, and microbial features of critically ill patients admitted to the ICU with a definite IE diagnosis. METHODS: We conducted a prospective case-series population study from January 1, 1998, to December 31, 2020. Patients were divided into 2 groups: 'Ward' (group 1) and 'ICU' patients (group 2), and a 1-year follow-up was performed. RESULTS: After performing a univariate and multivariate logistic regression analysis, we found that the independent predictors of ICU admission were vegetation diameter >10 mm, abnormal PaO2/FiO2 ratio, and acute heart failure. Five independent mortality risk factors were identified: SOFA score >14, not performing surgery, age >70 years, acute heart failure, and embolic complications. CONCLUSIONS: Infective endocarditis in-hospital mortality remains high. ICU admission and mortality can be predicted by independent risk factors.

Frequency and Clinical Significance of Atrial Cavities in situ Thrombosis: A Large-Scale Study and Literature Review.

Background: Atrial tachyarrhythmias are the main cause of atrial thrombosis, and are usually in the left appendage. The prevalence and causes of endocavitarian thrombosis have not been investigated in recent large-scale studies. Aim of our work was to describe the epidemiology, the clinical characteristics and predisposing factors of "extra-appendicular" atrial thrombosis and to report a systematic review of recent literature. Methods and Results: 5,862 consecutive adult patients referred to a transesophageal echocardiographic exam, were enrolled. A total of 175 subjects with Atrial Thrombosis were found with a prevalence of 2.98%; among those 22 was found in left (0.38%) and 2 in the right (0.03%) atrium. Among the 22 patients with left atrial thrombosis, 8 were associated with prosthetic valves, 4 with mitral stenosis and the remaining with hypercoagulative conditions (cancer, septic shock, eosinophilic pneumonia, cardiogenic shock and warfarin under-dosage in permanent atrial fibrillation and decompensated heart failure). Cancer was associated in one of the two patients with a right atrial clot. The review of the literature from 2000 to December 2019 revealed conflicting results of 48 case reports of atrial cavity thrombosis; pooling this data proved the rarity of extra-appendage thrombosis and confirmed its association with a valvular heart disease or a systemic hypercoagulable state. Conclusions: Atrial "extra-appendage" thrombosis is a rare condition usually associated to "valvular" atrial fibrillation (such as prosthetic valves and mitral stenosis). A minority, but significant, cases are secondary to a thrombophilic conditions. In absence of valvular heart disease an underlying condition should be sought.

Spontaneous abdominal bleeding associated with SARS-CoV-2 infection: causality or coincidence?

Authors present 6 cases of abdominal bleeding associated with COVID-19, representing 1.35% of all hospitalized COVID-19 patients and hypothesize that there could be, although not very frequently, a relationship between SARS-CoV2 and bleeding. They excluded a side effect of the low molecular weight heparin therapy that all patients underwent during the course of the disease or other possible causes. Alterations of the coagulation state or a weakness of the vascular wall due toa presumed endotheliitis SARS-CoV-2 infection induced, are hypothesized by the authors. Investigation and follow-up for possible hemorrhagic problems in patients with COVID-19 is recommended. In particular, clinicians should be vigilant about retroperitoneal hemorrhage in COVID-19 patients. In addition to the fact that these patients are being treated with anticoagulants, anemia and abdominal pain are the signs that should lead us to suspect this type of haemorrhage. More studies are needed to understand if COVID-19 can be directly associated with bleeding. (www.actabiomedica.it)

Triple Antithrombotic Therapy vs. Double Antithrombotic Therapy: One Scenario, 8 Questions, Many Conclusions.

In patients with atrial fibrillation undergoing percutaneous coronary intervention with the placement of stents, a triple antithrombotic therapy is empirically established, which consists of a combination of dual antithrombotic therapy (aspirin plus a P2Y12 inhibitor) and an oral anticoagulant agent. This choice is guided by the desirable result of reducing cerebrovascular and coronary ischemic events. However, there is an unwelcome outcome: an increased incidence of bleeding. On this matter, in 2018, a North American Perspective Update was published, about a year later it was followed by the publication of the European focus update on the dual antiplatelet therapy. After analysing the main differences between these two consensus documents, this review aims at examining the major studies on which they are based on, as a starting point to define the foundation of new trials that can help shed light on this prominent topic.

TAPSE: An old but useful tool in different diseases.

RV function is an important component of overall heart function with prognostic value in predicting symptomatic limitation and outcome in different cardiovascular pathologies. RV longitudinal contraction accounts for the majority of total RV function, up to 80%, as compared to transverse shortening. Calculation of RV volume and RV ejection fraction (RVEF) remains hampered by the complex RV geometry and we lack a good geometric model allowing the calculation of right ventricular ejection fraction; secondly, the large apical trabeculations of the right ventricle make the endocardial delineation more difficult to obtain than for the left ventricle. To notice, the gold standard method for the assessment of the chamber (MRI) is resource intensive and cannot be employed in many settings. Considering these problems, multiple parameters have been developed for the evaluation of RV systolic function: tricuspid annular plane systolic excursion (TAPSE), systolic excursion velocity (S'), and longitudinal strain by speckle tracking.

Additional value of Galectin-3 to BNP in acute heart failure patients with preserved ejection fraction.

BACKGROUND: Almost half of patients with acute heart failure have preserved ejection fraction (HFpEF). HFpEF is a diagnostic challenge using traditional investigation tools; Galectin-3 (Gal-3) is an emerging biomarker useful in individuals at risk for HF. The aim of our study is to analyse the relation and prognostic value of Gal-3, BNP and renal dysfunction in patients with HFpEF compared to patients with reduced ejection fraction (HFrEF). METHODS: We enrolled 98 patients with acute heart failure (AHF) and measured Gal-3, BNP, and estimated glomerular filtration rate (eGFR) within 12h of hospital admission. On the basis of echocardiographic findings we divided our sample into two groups: patients with HFrHF (ejection fraction<50%) or HFpEF (ejection fraction>50%). Patients were followed up at 6months. RESULTS: No differences in Gal-3 levels were found in the two subgroups (HFrEF: 19.5±5.1ng/mL; HFpEF: 20.5±8.7, p=0.56). Gal-3 was inversely related to renal dysfunction (LogGal-3 vs eGFR: r=-0.30, p=0.01) but did not correlate with LogBNP levels (r=0.07, p=0.55). Gal-3 was associated with more advanced diastolic dysfunction in HFpEF (p=0.009). In addition LogGal-3 was related to diastolic LV stiffness (all patients: r=0.45, p<0.001; HFpEF: r=0.64, p<0.001). Cox regression analysis showed that LogGal-3>1.30 was related to poor outcome independently from renal dysfunction and other risk factors only in HFpEF (univariate HR 23.98 [3.03-89.45]; p<0.001). Adjusted for renal dysfunction (HR 16.32 [1.98-34.09]; p=0.009). CONCLUSIONS: Gal-3 is not able to distinguish between HFrEF and HFpEF patients. However it is related to diastolic dysfunction severity and LV stiffness in HFpEF. Gal-3 demonstrates a prognostic role independently from renal dysfunction in subjects with HFpEF.