Culture-negative infective endocarditis (CNIE): impact on postoperative mortality.

INTRODUCTION: Poor postoperative outcomes have been reported after surgery for infective endocarditis (IE). Whether the absence of positive cultures impacts the prognosis remains a matter of discussion. The aim of this study was to evaluate the impact of negative cultures on the prognosis of surgically treated IE. METHODS: This was a single-center, retrospective study. From January 2000 to June 2019, all patients who underwent valvular surgery for IE were included in the study. The primary endpoint was early postoperative mortality. A covariate balancing propensity score was developed to minimize the differences between the culture-positive IE (CPIE) and culture-negative IE (CNIE) cohorts. Using the estimated propensity scores as weights, an inverse probability treatment weighting (IPTW) model was built to generate a weighted cohort. Then, to adjust for confounding related to CPIE and CNIE, a doubly robust method that combines regression model with IPTW by propensity score was adopted to estimate the causal effect of the exposure on the outcome. RESULTS: During the study period, 327 consecutive patients underwent valvular repair/replacement with the use of cardiopulmonary bypass and cardioplegic cardiac arrest for IE. Their mean age was 61.4 ± 15.4 years, and 246 were males (75.2%). Native valve IE and prosthetic valve IE accounted for 87.5% and 12.5% of cases, respectively. Aortic (182/327, 55.7%) and mitral valves (166/327, 50.8%) were mostly involved; 20.5% of isolated mitral valve diseases were repaired (22/107 patients). The tricuspid valve was involved in 10 patients (3.3%), and the pulmonary valve in 1 patient (<1%). Fifty-nine patients had multiple-valve disease (18.0%). Blood cultures were negative in 136/327 (41.6 %). A higher postoperative mortality was registered in CNIE than in CPIE patients (19% vs 9%, respectively, p = 0.01). The doubly robust analysis after IPTW by propensity score showed CNIE to be associated with early postoperative mortality (odds ratio 2.10; 95% CI, 1.04-4.26, p = 0.04). CONCLUSIONS: In our cohort, CNIE was associated with a higher early postoperative mortality in surgically treated IE patients after dedicated adjustment for confounding. In this perspective, any effort to improve preoperative microbiological diagnosis, thus allowing targeted therapeutic initiatives, might lead to overall better postoperative outcomes in surgically treated IE.

Unruptured aneurysm of the left sinus of valsalva causing coronary insufficiency: case report and review of the literature.

Aneurysm of the left sinus of Valsalva is extremely rare. Compression of the left coronary artery by such an aneurysm is an unusual complication of this condition and can cause coronary insufficiency. We describe the case of a 75-year-old woman who had an isolated unruptured aneurysm of the left coronary sinus with intraluminal thrombus, which caused coronary artery compression. We performed successful surgical correction by closing the mouth of the aneurysm without aortic valve replacement or coronary artery bypass grafting. A review of the world medical literature revealed 19 cases of sinus of Valsalva aneurysms that hindered the coronary arterial flow. The previously published reports of this rare condition and its treatment are discussed herein.

Aortic branch artery pseudoaneurysms associated with intramural hematoma: when and how to do endovascular embolization.

PURPOSE: To describe when and how to perform endovascular embolization of aortic branch artery pseudoaneurysms associated with type A and type B intramural hematoma (IMH) involving the descending thoracic and abdominal aorta (DeBakey I and III) that increased significantly in size during follow-up. MATERIALS AND METHODS: Sixty-one patients (39 men; mean ± standard deviation age 66.1 ± 11.2 years) with acute IMH undergoing at least two multidetector computed tomographic examinations during follow-up for 12 months or longer were enrolled. Overall, 48 patients (31 men, age 65.9 ± 11.5) had type A and type B IMH involving the descending thoracic and abdominal aorta (DeBakey I and III). RESULTS: Among the 48 patients, 26 (54 %; 17 men, aged 64.3 ± 11.4 years) had 71 aortic branch artery pseudoaneurysms. Overall, during a mean follow-up of 22.1 ± 9.5 months (range 12-42 months), 31 (44 %) pseudoaneurysms disappeared; 22 (31 %) decreased in size; two (3 %) remained stable; and 16 (22 %) increased in size. Among the 16 pseudoaneurysms with increasing size, five of these (three intercostal arteries, one combined intercostobronchial/intercostal arteries, one renal artery), present in five symptomatic patients, had a significant increase in size (thickness >10 mm; width and length >20 mm). These five patients underwent endovascular embolization with coils and/or Amplatzer Vascular Plug. In all patients, complete thrombosis and exclusion of aortic pseudoaneurysm and relief of back pain were achieved. CONCLUSION: Aortic branch artery pseudoaneurysms associated with type A and type B IMH involving the descending thoracic and abdominal aorta (DeBakey I and III) may be considered relatively benign lesions. However, a small number may grow in size or extend longitudinally with clinical symptoms during follow-up, and in these cases, endovascular embolization can be an effective and safe procedure.

Relay NBS graft with the plus delivery system to improve deployment in aortic Arch with small radius curve.

The purpose of this report is to describe deployment of the Relay NBS Thoracic Stent Graft with the Plus Delivery System (Bolton Medical, Sunrise, FL) in a flexible resin arch model with a 15-mm radius curve as well as our preliminary clinical results. The Relay NBS graft with the Plus Delivery System was evaluated by way of bench testing, which was performed with stent grafts with diameters ranging from 24 to 46 mm and lengths ranging from 100 to 250 mm in flexible resin arch models with a 15-mm arch radius of curvature. The deployment sequence was analyzed. The Relay NBS graft with the Plus Delivery System was deployed in two patients, respectively, having a 6.5-cm penetrating aortic ulcer of the proximal third of the descending thoracic aorta and a DeBakey type-I aortic dissection with chronic false lumen dilatation after surgery due to an entry site at the distal thoracic aorta. Bench tests showed proper conformation and apposition of the Relay NBS graft with the Plus Delivery System in the flexible resin model. This stent graft was deployed successfully into the two patients with a correct orientation of the first stent and without early or late complications. The Relay NBS graft with the Plus Delivery System ensures an optimal conformation and apposition of the first stent in the aortic arch with a small radius of curvature.

Left main coronary stenosis as a consequence of bentall operation: percutaneous treatment.

A 65-year-old man suffering from ascending aorta aneurysm and atherosclerotic three vessel disease without left main involvement underwent aortic root replacement with coronary ostia reimplantation according to the modified Bentall technique and multiple coronary artery bypass grafts. Gelatin-resorcin-formaldehyde glue was used to reinforce the aortic coronary buttons and to facilitate hemostasis. Five months after surgery, the patient experienced rapidly worsening effort angina. Coronary angiography showed severe left main narrowing. The considerable amount of time that elapsed between surgery and the onset of symptoms implies that the problem was not related to an imperfect suture technique, but was most likely caused by an inflammatory and proliferative response to the glue that had been used. We performed elective percutaneous coronary intervention and stenting of the protected coronary vessel without technical difficulties and with a satisfactory final result. The patient is currently symptom-free after 1 year's follow-up.

Percutaneous treatment of left main coronary stenosis as a late complication of bentall operation for acute aortic dissection.

Severe ostial left main coronary stenosis developed 35 days after successful Bentall-type operation for acute aortic dissection. Treatment of this kind of complication is usually performed with open chest coronary artery bypass grafting. In our case, treatment with percutaneous transluminal coronary angioplasty and stenting of the lesion immediately after diagnostic coronary angiography was performed successfully, with persisting good results at 9-month clinical follow-up.