Outpatient continuous-infusion benzylpenicillin combined with either gentamicin or ceftriaxone for enterococcal endocarditis.

BACKGROUND: Treatment regimens requiring multiple daily dosing for enterococcal endocarditis are challenging to deliver in the outpatient setting. Continuous-infusion benzylpenicillin via a 24 h elastomeric infusor, combined with either once-daily gentamicin or ceftriaxone, requires only one nursing encounter daily and is commonly used in New Zealand. OBJECTIVES: To assess the therapeutic success and adverse antibiotic effects of these regimens. METHODS: A retrospective observational case series from multiple hospitals of patients aged 15 years or over with enterococcal endocarditis diagnosed between July 2013 and June 2019 who received at least 14 days of outpatient continuous-infusion benzylpenicillin combined with either gentamicin or ceftriaxone for synergy. RESULTS: Forty-three episodes of enterococcal endocarditis in 41 patients met inclusion criteria. The primary synergy antibiotic was gentamicin in 20 episodes and ceftriaxone in 23 episodes. For the 41 initial treatment courses, 31 (76%) patients were cured, 3 (7%) patients developed relapsed endocarditis during or following antibiotic treatment and 7 (17%) patients continued with long-term suppressive oral amoxicillin following IV antibiotic treatment. There was no difference in the relapse rate between the two groups (P = 0.59). Seven (35%) adverse antibiotic effects were documented in the gentamicin group and none in the ceftriaxone group (P < 0.01). Two deaths (5%) occurred within the 6 month follow-up period. CONCLUSIONS: Outpatient treatment of enterococcal endocarditis with continuous-infusion benzylpenicillin combined with either once-daily gentamicin or ceftriaxone following a period of inpatient treatment is usually effective. A significantly higher rate of adverse effects was seen with gentamicin, favouring ceftriaxone as the initial synergy antibiotic.

Performance of risk models predicting cardiac complications in pregnant women with congenital heart disease: a meta-analysis.

Accurate risk stratification is important in pregnant women including the growing population with congenital heart disease (CHD). We meta-analysed the performance of risk models for CHD women. Six studies with 3426 pregnancies were studied, with cardiac complication rates of 6.7-20.6%. Pooled c-statistics (95% confidence interval) for scores were mWHO 0.71 (0.65-0.76), CARPREG 0.66 (0.61-0.71) and ZAHARA 0.71 (0.65-0.76). Current risk models had at best moderate discrimination for CHD women with significant room for improvement.

Assessment of Disease Progression in Patients With Repaired Tetralogy of Fallot Using Cardiac Magnetic Resonance Imaging: A Systematic Review.

AIMS: Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease with a growing population of adult survivors. Late pulmonary outflow tract and pulmonary valve postoperative complications are frequent, leading to long-term risks such as right heart failure and sudden death secondary to arrhythmias. Cardiac magnetic resonance imaging (CMR) is the gold standard for assessment of cardiac function in patients with repaired ToF. We aimed to determine the most useful CMR predictors of disease progression and the optimal frequency of CMR. METHODS AND RESULTS: We systematically reviewed PubMed from inception until 29 April 2019 for longitudinal studies assessing the relationship between CMR features and disease progression in repaired ToF. Fourteen (14) studies were identified. Multiple studies showed that impaired right and left ventricular function predict subsequent disease progression. Right ventricular end diastolic volume, while being associated with disease progression when analysed alone, was generally not associated with disease progression on multivariate analysis. Severity of tricuspid regurgitation and pulmonary regurgitation likewise did not show a consistent association with subsequent events. A number of non-CMR factors were also identified as being associated with disease progression, in particular QRS duration and older age at repair. Restrictive right ventricular physiology was not consistently an independent predictor of events. CONCLUSION: Impaired right and left ventricular function are the most consistent independent predictors of disease progression in repaired ToF. The optimal timing of repeat cardiac imaging remains controversial. Large scale prospective studies will provide important information to guide clinical decision making in this area.

The impact of illness perceptions and disease severity on quality of life in congenital heart disease.

BACKGROUND: Despite an increasing prevalence of adults living with a CHD, little is known about the psychosocial impact of CHD. We sought to investigate the relative impact of disease severity and patients' perceptions about their condition on depression, anxiety, and quality of life over a period of a year. METHODS: A total of 110 patients aged over 16 years completed an initial questionnaire containing measures for anxiety, depression, quality of life, and illness perceptions when they attended the Adult Congenital Heart Disease Clinic. Cardiologists rated the patients' disease severity and illness course. A year later, patients were invited to complete the same measures. Regression analyses were performed to determine the relative impact of illness perceptions and disease severity on psychological outcomes a year later. RESULTS: At baseline, 23% of the study population had depressive symptoms and 30% had elevated trait anxiety. After controlling for associations with disease-related variables, illness perceptions explained 28% of the variance in depression, 40% anxiety, and 27% overall quality of life at baseline. Baseline illness perceptions bivariately predicted quality of life, cardiac anxiety, and depression 1 year later, and regression analyses controlling for other factors showed that they were significant predictors of outcomes 1 year later. CONCLUSION: Symptoms of depression and anxiety are common among adults with CHD. Patients' illness perceptions are related to psychological outcomes, especially cross-sectionally. Future research could investigate whether an intervention to discuss patients' perceptions about their CHD can improve mental health and quality of life.

Correcting bias in cardiac geometries derived from multimodal images using spatiotemporal mapping.

Cardiovascular imaging studies provide a multitude of structural and functional data to better understand disease mechanisms. While pooling data across studies enables more powerful and broader applications, performing quantitative comparisons across datasets with varying acquisition or analysis methods is problematic due to inherent measurement biases specific to each protocol. We show how dynamic time warping and partial least squares regression can be applied to effectively map between left ventricular geometries derived from different imaging modalities and analysis protocols to account for such differences. To demonstrate this method, paired real-time 3D echocardiography (3DE) and cardiac magnetic resonance (CMR) sequences from 138 subjects were used to construct a mapping function between the two modalities to correct for biases in left ventricular clinical cardiac indices, as well as regional shape. Leave-one-out cross-validation revealed a significant reduction in mean bias, narrower limits of agreement, and higher intraclass correlation coefficients for all functional indices between CMR and 3DE geometries after spatiotemporal mapping. Meanwhile, average root mean squared errors between surface coordinates of 3DE and CMR geometries across the cardiac cycle decreased from 7 ± 1 to 4 ± 1 mm for the total study population. Our generalised method for mapping between time-varying cardiac geometries obtained using different acquisition and analysis protocols enables the pooling of data between modalities and the potential for smaller studies to leverage large population databases for quantitative comparisons.

Atrial fibrillation cardiac radioablation target visibility on magnetic resonance imaging.

Magnetic resonance imaging (MRI) guided cardiac radioablation (CR) for atrial fibrillation (AF) is a promising treatment concept. However, the visibility of AF CR targets on MRI acquisitions requires further exploration and MRI sequence and parameter optimization has not yet been performed for this application. This pilot study explores the feasibility of MRI-guided tracking of AF CR targets by evaluating AF CR target visualization on human participants using a selection of 3D and 2D MRI sequences.MRI datasets were acquired in healthy and AF participants using a range of MRI sequences and parameters. MRI acquisition categories included 3D free-breathing acquisitions (3Dacq), 2D breath-hold ECG-gated acquisitions (2DECG-gated), stacks of 2D breath-hold ECG-gated acquisitions which were retrospectively interpolated to 3D datasets (3Dinterp), and 2D breath-hold ungated acquisitions (2Dreal-time). The ease of target delineation and the presence of artifacts were qualitatively analyzed. Image quality was quantitatively analyzed using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and non-uniformity. Confident 3D target delineation was achievable on all 3Dinterp datasets but was not possible on any of the 3Dacq datasets. Fewer artifacts and significantly better SNR, CNR and non-uniformity metrics were observed with 3Dinterp compared to 3Dacq. 2Dreal-time datasets had slightly lower SNR and CNR than 2DECG-gated and 3Dinterp n datasets. AF CR target visualization on MRI was qualitatively and quantitatively evaluated. The study findings indicate that AF CR target visualization is achievable despite the imaging challenges associated with these targets, warranting further investigation into MRI-guided AF CR treatments.

MITEA: A dataset for machine learning segmentation of the left ventricle in 3D echocardiography using subject-specific labels from cardiac magnetic resonance imaging.

Segmentation of the left ventricle (LV) in echocardiography is an important task for the quantification of volume and mass in heart disease. Continuing advances in echocardiography have extended imaging capabilities into the 3D domain, subsequently overcoming the geometric assumptions associated with conventional 2D acquisitions. Nevertheless, the analysis of 3D echocardiography (3DE) poses several challenges associated with limited spatial resolution, poor contrast-to-noise ratio, complex noise characteristics, and image anisotropy. To develop automated methods for 3DE analysis, a sufficiently large, labeled dataset is typically required. However, ground truth segmentations have historically been difficult to obtain due to the high inter-observer variability associated with manual analysis. We address this lack of expert consensus by registering labels derived from higher-resolution subject-specific cardiac magnetic resonance (CMR) images, producing 536 annotated 3DE images from 143 human subjects (10 of which were excluded). This heterogeneous population consists of healthy controls and patients with cardiac disease, across a range of demographics. To demonstrate the utility of such a dataset, a state-of-the-art, self-configuring deep learning network for semantic segmentation was employed for automated 3DE analysis. Using the proposed dataset for training, the network produced measurement biases of -9 ± 16 ml, -1 ± 10 ml, -2 ± 5 %, and 5 ± 23 g, for end-diastolic volume, end-systolic volume, ejection fraction, and mass, respectively, outperforming an expert human observer in terms of accuracy as well as scan-rescan reproducibility. As part of the Cardiac Atlas Project, we present here a large, publicly available 3DE dataset with ground truth labels that leverage the higher resolution and contrast of CMR, to provide a new benchmark for automated 3DE analysis. Such an approach not only reduces the effect of observer-specific bias present in manual 3DE annotations, but also enables the development of analysis techniques which exhibit better agreement with CMR compared to conventional methods. This represents an important step for enabling more efficient and accurate diagnostic and prognostic information to be obtained from echocardiography.

Cardiac radioablation for atrial fibrillation: Target motion characterization and treatment delivery considerations.

PURPOSE: The safe delivery of cardiac radioablation (CR) for atrial fibrillation (AF) is challenged by multi-direction target motion, cardiac rate variability, target proximity to critical structures, and the importance of complete target dose coverage for therapeutic benefit. Careful selection of appropriate treatment procedures is therefore essential. This work characterizes AF cardiac radioablation target motion and target proximity to surrounding structures in both healthy and AF participants to guide optimal treatment technique and technology choice. METHODS: Ten healthy participants and five participants with AF underwent MRI acquisition. Multi-slice, cardiac-gated, breath-hold cines were acquired and interpolated to create three-dimensional images for 18-30 cardiac phases. Treatment targets at the left and right pulmonary vein ostia (CTVLeft and CTVRight respectively) and adjacent cardiac structures were contoured and their displacements throughout the cardiac cycle were assessed. Target proximity to surrounding structures were measured. Free-breathing real-time two-dimensional cine images were also acquired at 4 Hz frequency for between 1- and 2-min duration. The motion of easily identifiable points within the target, diaphragm and sternum was measured to assess respiratory motion. RESULTS: Target motion due to cardiac contraction was most prominent in the medial-lateral direction and of 4-5 mm magnitude. CTVRight displacements were smaller in participants with AF than healthy participants in normal sinus rhythm. Nearby cardiac structures often moved with different magnitudes and motion trajectories. CTVLeft and/or CTVRight were in direct contact with the esophagus in 73% of participants. Target motion due to respiration was most prominent in the superior-inferior direction and of 13-14 mm magnitude in both healthy and AF participants. CONCLUSION: AF CR target motion and relative displacement was characterized. The combination of target motion magnitude and relative displacement to critical structures highlights the importance of personalizing motion compensation techniques for effective AF CR treatments.

MRI-guided cardiac-induced target motion tracking for atrial fibrillation cardiac radioablation.

BACKGROUND AND PURPOSE: Atrial fibrillation (AF) cardiac radioablation (CR) challenges radiotherapy tracking: multiple small targets close to organs-at-risk undergo rapid differential cardiac contraction and respiratory motion. MR-guidance offers a real-time target tracking solution. This work develops and investigates MRI-guided tracking of AF CR targets with cardiac-induced motion. MATERIALS AND METHODS: A direct tracking method (Trackingdirect) and two indirect tracking methods leveraging population-based surrogacy relationships with the left atria (Trackingindirect_LA) or other target (Trackingindirect_target) were developed. Tracking performance was evaluated using transverse ECG-gated breathhold MRI images from 15 healthy and 10 AF participants. Geometric and volumetric tracking errors were calculated, defined as the difference between the ground-truth and tracked target centroids and volumes respectively. Transverse, breath-hold, noncardiac-gated cine images were acquired at 4 Hz in 5 healthy and 5 AF participants to qualitatively characterize tracking performance on images more comparable to MRILinac acquisitions. RESULTS: The average 3D geometric tracking errors for Trackingdirect, Trackingindirect_LA and Trackingindirect_target respectively were 1.7 ± 1.2 mm, 1.6 ± 1.1 mm and 1.9 ± 1.3 mm in healthy participants and 1.7 ± 1.3 mm, 1.5 ± 1.0 mm and 1.7 ± 1.2 mm in AF participants. For Trackingdirect, 88% of analyzed images had 3D geometric tracking errors <3 mm and the average volume tracking error was 1.7 ± 1.3 cc. For Trackingdirect on non-cardiac-gated cine images, tracked targets overlapped organsat-risk or completely missed the target area on 2.2% and 0.08% of the images respectively. CONCLUSION: The feasibility of non-invasive MRI-guided tracking of cardiac-induced AF CR target motion was demonstrated for the first time, showing potential for improving AF CR treatment efficacy.

Right Ventricular Flow Vorticity Relationships With Biventricular Shape in Adult Tetralogy of Fallot.

Remodeling in adults with repaired tetralogy of Fallot (rToF) may occur due to chronic pulmonary regurgitation, but may also be related to altered flow patterns, including vortices. We aimed to correlate and quantify relationships between vorticity and ventricular shape derived from atlas-based analysis of biventricular shape. Adult rToF (n = 12) patients underwent 4D flow and cine MRI imaging. Vorticity in the RV was computed after noise reduction using a neural network. A biventricular shape atlas built from 95 rToF patients was used to derive principal component modes, which were associated with vorticity and pulmonary regurgitant volume (PRV) using univariate and multivariate linear regression. Univariate analysis showed that indexed PRV correlated with 3 modes (r = -0.55,-0.50, and 0.6, all p < 0.05) associated with RV dilatation and an increase in basal bulging, apical bulging and tricuspid annulus tilting with more severe regurgitation, as well as a smaller LV and paradoxical movement of the septum. RV outflow and inflow vorticity were also correlated with these modes. However, total vorticity over the whole RV was correlated with two different modes (r = -0.62,-0.69, both p < 0.05). Higher vorticity was associated with both RV and LV shape changes including longer ventricular length, a larger bulge beside the tricuspid valve, and distinct tricuspid tilting. RV flow vorticity was associated with changes in biventricular geometry, distinct from associations with PRV. Flow vorticity may provide additional mechanistic information in rToF remodeling. Both LV and RV shapes are important in rToF RV flow patterns.

Complimentary roles for N-terminal pro-B-type natriuretic peptide and spirometry to assess functional capacity in patients with complex mixed heart valve disease.

BACKGROUND: Assessing the effects of valvular heart disease on functional capacity is important for optimal timing of surgery. AIM: To determine whether N-terminal pro-B type natriuretic peptide (NT-proBNP) and lung spirometry predict maximum oxygen consumption (pVO(2)) on cardio-pulmonary exercise testing in patients with mixed heart valve disease. METHODS: Forty-five clinically stable patients with moderate-severe stenosis and/or regurgitation of the aortic, mitral and/or tricuspid valves were studied. The ability of echocardiography, NT-proBNP, forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) to predict impaired pVO(2) was determined. RESULTS: On univariate analysis the natural logarithm of NT-proBNP explained more of the variation in pVO(2) (r(2) = 0.40, p < 0.0001) than valve severity score (r(2) = 0.20, p = 0.002), pulmonary artery pressure (r(2) = 0.21, p = 0.005), left atrial area index (r(2) = 0.25, p = 0.001) or LV ejection fraction (r(2) = 0.02, p = 0.4). Low lean body weight (r(2) = 0.21, p = 0.002), FEV1 (r(2) = 0.26, p = 0.0003) and FVC (r(2) = 0.20, p = 0.002) were also associated with pVO(2). In multi-variable analysis independent determinants of pVO(2) were NT-proBNP (r(2) = 0.27, p = 0.001), FVC (r(2) = 0.20, p = 0.0002) and lean body weight (r(2) = 0.23, p = 0.001). NT-proBNP and FVC together were better predictors of pVO(2) < 60% (C statistic = 0.83, 95% CI 0.71, 0.95) than either NT-proBNP (C = 0.80, 95% CI 0.66, 0.94) or FVC (C =0.73, 95% CI 0.57, 0.89) alone. NT-proBNP, FVC and age also predicted excessive ventilation on cardio-pulmonary exercise (combined r(2) = 0.54, p < 0.0001). CONCLUSION: In patients with mixed heart valve disease NT-proBNP and spirometry provide a more reliable assessment of functional capacity than assessment by echocardiography and symptoms alone.

Complex valve disease: pre-surgical functional capacity evaluation using peak oxygen consumption.

BACKGROUND AND AIM OF THE STUDY: Complex heart valve disease constitutes both mixed and multiple valve pathologies that coexist in a single heart. The chronicity of complex valve disease results in a slow decline in functional capacity. Currently, very few data exist relating to chronic complex valve disease. The clinical assessment of exertional dyspnea (NYHA class) is central to the decision to operate and predict a prognosis. Dyspnea causes significant functional limitations. Peak oxygen consumption (peak VO2) is the 'gold standard' of objectively measuring functional aerobic capacity, and is an important predictor of prognosis. The onset of dyspnea is the most common indication for valve surgery. The study aim, in patients with complex valve disease, was to: (i) objectively assess functional aerobic capacity using peak VO2; and (ii) compare the differences between NYHA classes I and II in relation to body composition, echocardiographic severity, and functional capacity METHODS: A total of 45 patients with complex valve disease, who had been referred for the timing of surgery, was evaluated. The control group comprised 15 healthy subjects. All patients underwent a clinical assessment (to determine NYHA class), echocardiography and cardiopulmonary testing (peak VO2). RESULTS: Patients with complex valve disease achieved significantly lower peak VO2 values than controls (16 +/- 5.9 versus 31.4 +/- 5.9 ml/kg/min; p = 0.0001). The peak VO2 (percentage predicted) was significantly different between asymptomatic (NYHA class I) patients (70.9 +/- 20%) and symptomatic (NYHA class II) patients (55.1 +/- 21%; p = 0.003), with an overlap between classes. There was no significant difference in the echocardiographic severity of the valve lesions between NYHA classes. In a multivariable regression analysis, the peak VO2 and VEN/VCO2 slope were powerful predictors of poor outcome (Hazards ratio 2.15, 5.62; p <0.05). CONCLUSION: Patients with complex valve disease show significant functional capacity impairment, which may be difficult to detect from their clinical presentation. Consequently, peak VO2 measurements are required for the objective evaluation of functional capacity. The detection of a decline in peak VO2 will improve the timing of valve replacement and repair, and avoid adverse outcomes.

Estimation of myocardial strain from non-rigid registration and highly accelerated cine CMR.

Sparsely sampled cardiac cine accelerated acquisitions show promise for faster evaluation of left-ventricular function. Myocardial strain estimation using image feature tracking methods is also becoming widespread. However, it is not known whether highly accelerated acquisitions also provide reliable feature tracking strain estimates. Twenty patients and twenty healthy volunteers were imaged with conventional 14-beat/slice cine acquisition (STD), 4× accelerated 4-beat/slice acquisition with iterative reconstruction (R4), and a 9.2× accelerated 2-beat/slice real-time acquisition with sparse sampling and iterative reconstruction (R9.2). Radial and circumferential strains were calculated using non-rigid registration in the mid-ventricle short-axis slice and inter-observer errors were evaluated. Consistency was assessed using intra-class correlation coefficients (ICC) and bias with Bland-Altman analysis. Peak circumferential strain magnitude was highly consistent between STD and R4 and R9.2 (ICC = 0.876 and 0.884, respectively). Average bias was -1.7 ± 2.0 %, p < 0.001, for R4 and -2.7 ± 1.9 %, p < 0.001 for R9.2. Peak radial strain was also highly consistent (ICC = 0.829 and 0.785, respectively), with average bias -11.2 ± 18.4 %, p < 0.001, for R4 and -15.0 ± 21.2 %, p < 0.001 for R9.2. STD circumferential strain could be predicted by linear regression from R9.2 with an R2 of 0.82 and a root mean squared error of 1.8 %. Similarly, radial strain could be predicted with an R2 of 0.67 and a root mean squared error of 21.3 %. Inter-observer errors were not significantly different between methods, except for peak circumferential strain R9.2 (1.1 ± 1.9 %) versus STD (0.3 ± 1.0 %), p = 0.011. Although small systematic differences were observed in strain, these were highly consistent with standard acquisitions, suggesting that accelerated myocardial strain is feasible and reliable in patients who require short acquisition durations.

Cardiac output as a predictor in congenital heart disease: Are we stating the obvious?

BACKGROUND: Significant pulmonary regurgitation, declining right-sided ejection fraction, increased right ventricular (RV) volumes as well as left ventricular (LV) dysfunction have all been identified as predictors of poor outcomes in patients with congenital heart disease (CHD). The prognostic value of the cardiac output (CO) in these patients however has never been studied. METHODS: All consecutive ambulatory adult patients with CHD referred for magnetic resonance imaging (MRI) at the Montreal Children's Hospital between June 2007 and May 2009 were included. Right ventricular (RV) and left ventricular (LV) variables including end diastolic and end systolic volumes (EDV, ESV respectively), ejection fractions (EF) and regurgitant volumes were obtained. Cardiac index (CI) was calculated. Patients were followed for cardiac-related hospitalizations and cardiac interventions. RESULTS: Ninety-six patients were included. Median follow up was 3.9 ± 1.4 years. Nineteen percent of patients had a systemic CI<2.4 l/min/m(2). LVEDV, LVEF and RVEF were significantly diminished in the low CI group with a significant increase in RVESV and total regurgitant volume. Best predictors of low CI were LVEF (AUC=0.74), RVEF (AUC=0.71), total RV regurgitant volume (AUC=0.64) and RVESV (AUC=0.563). Low systemic CI was the best predictor of cardiac-related hospitalizations (hazard ratio 3.5, 95% confidence interval 1.5-8.5) and cardiac interventions (hazard ratio 2.2, 95% confidence interval 1.3-4.0), superior to LVEF, RVEF, total regurgitant volume and RVESV parameters. CONCLUSIONS: In patients with congenital heart disease, cardiac index is the best predictor of cardiac hospitalizations and cardiac interventions.

The value of CT cardiac angiography and CT calcium score testing in a modern cardiology service in New Zealand: a report of a single centre eight-year experience from 5,237 outpatient procedures.

BACKGROUND: Computed tomographic (CT) cardiac angiography is of increasing value in several areas of patient management in cardiology. We assessed the ability of CT cardiac angiography to effectively 'rule out' severe coronary stenoses in patients presenting with 'atypical' symptoms and/or an equivocal stress test, which offers a new approach to the management of coronary artery disease. We also examined the use of the CT calcium score test in cardiovascular (CVS) risk assessment. METHODS: From a large single centre (Mercy Hospital) in Auckland, using a prospectively acquired, comprehensive database, we audited the entire eight-year experience of 5,169 patients (7/8/06 to 31/1/14) who underwent 5,237 64-slice computed tomographic (CT) cardiac angiogram or CT calcium score tests (GE Lightspeed scanner). RESULTS: From 5,169 patients there were 5,237 CT procedures. The mean patient age was 57 (SD 10) years; 42% patients were female. Of the 3,603 (69%) full CT cardiac angiogram scans, 3,509 (67%) included a calcium score test. One thousand four hundred and eighty-three (28%) of scans were a calcium score test only. Of the 3,603 (69%) full CT cardiac angiogram scans, it was possible to 'rule out' significant coronary atheroma (stenosis ≥50%) in 2,947 (82%) of these procedures. Of the 4,903 (94%) patients who had a CT calcium score test, in whom we could calculate the NZ Framingham-based CVS risk, it was possible to reassign 532 (22%) of these patients who were previously thought to be at 'low risk' to be at a higher CVS risk. CONCLUSION: CT cardiac angiography has become established in the modern management of cardiology patients. It has particular value as a tool to 'rule out' severe coronary stenoses, and as a tool to give a more accurate assessment of CVS risk. It adds significant value to the care of many patients within an established cardiology practice.

The role of echocardiography in Staphylococcus aureus bacteraemia at Auckland City Hospital.

AIMS: Current guidelines recommend echocardiography in all episodes of Staphylococcus aureus bacteraemia (SAB). This study aimed to determine whether a very low-risk group of patients with SAB could be found in whom echocardiography was of no incremental diagnostic value for the diagnosis of infective endocarditis. METHODS: Using the ANZCOSS dataset, we identified 574 eligible episodes of adult SAB at Auckland District Health Board (ADHB) between 2007 and 2012, and retrospectively obtained additional microbiological and clinical data. Prevalence of IE was determined using the modified Duke's criteria for diagnosis of IE. Multivariate logistic regression analysis was used to determine whether risk factors were independently associated with IE, and we also assessed their negative predictive value (NPV). RESULTS: Transthoracic and/or transoesophageal echocardiography was performed in 370 (65%) episodes of SAB. The prevalence of clinically definite and clinically possible IE was 5.6% and 8.5%, respectively. Thirty day all-cause mortality was 11.7%. The factors with the highest NPV when absent in hospital-acquired SAB were non central venous line-associated bacteraemia (100%), persistent bacteraemia (96%), and presence of a prosthetic valve or cardiac rhythm management (CRM) device (95%). When none of these three criteria were present the NPV was 100% (99-100%). CONCLUSIONS: A group of very low risk patients was found in our study: central line-associated SAB without prosthetic valves / CRM devices and without persistent bacteraemia. These patients had no episodes of IE and echocardiography is of no incremental diagnostic benefit.

Prognostic significance of left atrial appendage "sludge" in patients with atrial fibrillation: a new transesophageal echocardiographic thromboembolic risk factor.

BACKGROUND: When stratifying thromboembolic risk to patients with atrial fibrillation (AF), left atrial appendage (LAA) thrombus is currently the only echocardiographic index that absolutely contraindicates cardioversion. The aim of this study was to identify the predictors of LAA "sludge" and its impact on subsequent thromboembolism and survival in patients with AF. METHODS: A total of 340 patients (mean age, 66 ± 12 years; 75% men) who underwent transesophageal echocardiography to exclude LAA thrombus before electrical cardioversion or radiofrequency pulmonary vein isolation) for AF were retrospectively studied. LAA sludge was defined as a dynamic, viscid, layered echodensity without a discrete mass, visualized throughout the cardiac cycle. Follow-up was obtained after a mean of 6.7 ± 3.7 years, and patients were analyzed according to LAA thrombus (n = 62 [18%]), sludge (n = 47 [14%]), or spontaneous echocardiographic contrast (n = 84 [25%]). Patients without these transesophageal echocardiographic characteristics served as controls (n = 147 [43%]). RESULTS: LAA sludge was independently predicted by enlarged left atrial area (odds ratio, 4.54; 95% confidence interval [CI], 2.38-8.67; P < .001), reduced LAA emptying velocity (odds ratio, 12.7; 95% CI, 6.11-26.44; P < .001), and reduced left ventricular ejection fraction (odds ratio, 2.11; 95% CI, 1.03-4.32; P < .001). Thromboembolic event and all-cause mortality rates in patients with sludge were 23% and 57%, respectively. Multiple logistic regression analyses identified the presence of LAA sludge to be independently associated with thromboembolic complications (adjusted hazard ratio, 3.43; 95% CI, 1.42-8.28; P = .006) and all-cause mortality (adjusted hazard ratio, 2.02; 95% CI, 1.22-3.36; P = .007). CONCLUSION: Sludge within the LAA is independently associated with subsequent thromboembolic events and all-cause mortality in patients with AF.

Diagnosis of pulmonary hypertension in the congenital heart disease adult population impact on outcomes.

OBJECTIVES: The aim of this study was to assess the impact of the diagnosis of pulmonary hypertension (PH) on mortality, morbidity, and health services utilization (HSU) in an adult congenital heart disease (CHD) population. BACKGROUND: Although PH is a well-recognized complication of CHD, population-based studies of its significance on the survival and functional capacity of patients are uncommon. METHODS: A retrospective longitudinal cohort study was conducted in an adult CHD population with 23 years of follow-up, from 1983 to 2005. The prevalence of PH was measured in 2005. Mortality, morbidity, and HSU outcomes were compared between patients with and without diagnoses of PH using multivariate Cox (mortality and morbidity) and Poisson (HSU) regression models within a subcohort matched for age and CHD lesion type. RESULTS: Of 38,430 adults alive with CHD in 2005, 2,212 (5.8%) had diagnoses of PH (median age 67 years, 59% women). The diagnosis of PH increased the all-cause mortality rate of adults with CHD more than 2-fold compared with patients without PH (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.41 to 2.99). Morbid complications including heart failure and arrhythmia occurred with a 3-fold higher risk compared with patients without PH (HR: 3.01; 95% CI: 2.80 to 3.22). The utilization of inpatient and outpatient services was increased, especially cardiac catheterization, excluding the index diagnostic study (rate ratio: 5.04; 95% CI: 4.27 to 5.93) and coronary and intensive care hospitalizations (rate ratio: 5.03; 95% CI: 4.86 to 5.20). CONCLUSIONS: A diagnosis of PH in adults with CHD is associated with a more than 2-fold higher risk for all-cause mortality and 3-fold higher rates of HSU, reflecting high morbidity.