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SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Técnicas Microbiológicas , Infecciones Relacionadas con Prótesis , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Técnicas Microbiológicas/métodos , Bacterias/aislamiento & purificación , Bacterias/clasificación , Bacterias/genética , Laboratorios Clínicos , Técnicas de Diagnóstico Molecular/métodosRESUMEN
Among 302 episodes with prosthetic valve endocarditis (PVE), one-year mortality was 31%. There was no evidence indicating that early-onset PVE within 6 months from valve surgery led to a worse outcome compared to late-onset PVE (21% versus 32%; p=0.126), despite similar redo valve surgeries across both categories.
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BACKGROUND: Since publication of Duke criteria for infective endocarditis (IE) diagnosis, several modifications have been proposed. We aimed to evaluate the diagnostic performance of the Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) 2023 criteria compared to prior versions from 2000 (Duke-Li 2000) and 2015 (Duke-ESC [European Society for Cardiology] 2015). METHODS: This study was conducted at 2 university hospitals between 2014 and 2022 among patients with suspected IE. A case was classified as IE (final IE diagnosis) by the Endocarditis Team. Sensitivity for each version of the Duke criteria was calculated among patients with confirmed IE based on pathological, surgical, and microbiological data. Specificity for each version of the Duke criteria was calculated among patients with suspected IE for whom IE diagnosis was ruled out. RESULTS: In total, 2132 episodes with suspected IE were included, of which 1101 (52%) had final IE diagnosis. Definite IE by pathologic criteria was found in 285 (13%), 285 (13%), and 345 (16%) patients using the Duke-Li 2000, Duke-ESC 2015, or the Duke-ISCVID 2023 criteria, respectively. IE was excluded by histopathology in 25 (1%) patients. The Duke-ISCVID 2023 clinical criteria showed a higher sensitivity (84%) compared to previous versions (70%). However, specificity of the new clinical criteria was lower (60%) compared to previous versions (74%). CONCLUSIONS: The Duke-ISCVID 2023 criteria led to an increase in sensitivity compared to previous versions. Further studies are needed to evaluate items that could increase sensitivity by reducing the number of IE patients misclassified as possible, but without having detrimental effect on specificity of Duke criteria.
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Enfermedades Transmisibles , Endocarditis Bacteriana , Endocarditis , Prótesis Valvulares Cardíacas , Humanos , Endocarditis Bacteriana/diagnóstico , Endocarditis/diagnóstico , Prótesis Valvulares Cardíacas/microbiología , Fluorodesoxiglucosa F18RESUMEN
An 86-year-old female with history of surgical aortic valve replacement presented with clinical signs of heart failure. Echocardiography revealed a reduction in left ventricular systolic function and severe bioprosthetic aortic valve dysfunction. This is the first reported case of valve-in-valve transcatheter aortic valve replacement with concomitant undermining iatrogenic coronary obstruction with radiofrequency needle procedure in a surgical bioprosthetic valve.
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Estenosis de la Válvula Aórtica , Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Enfermedad Iatrogénica , Diseño de Prótesis , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Anciano de 80 o más Años , Femenino , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Resultado del Tratamiento , Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Ablación por Catéter/efectos adversos , Falla de Prótesis , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Lesiones Cardíacas/etiología , Lesiones Cardíacas/diagnóstico por imagen , Lesiones Cardíacas/terapia , Agujas , Función Ventricular Izquierda , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/etiología , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Angiografía CoronariaRESUMEN
PURPOSE: The duration of antibiotic treatment for prosthetic valve endocarditis caused by Streptococcus spp. is largely based on clinical observations and expert opinion rather than empirical studies. Here we assess the impact of a shorter antibiotic duration. OBJECTIVES: To assess the impact of antibiotic treatment duration for streptococcal prosthetic valve endocarditis on 12-month mortality as well as subsequent morbidity resulting in additional cardiac surgical interventions, and rates of relapse and reinfection. METHODS: This retrospective multisite (N= 3) study examines two decades of data on patients with streptococcal prosthetic valve endocarditis receiving either 4 or 6 weeks of antibiotics. Overall mortality, relapse, and reinfection rates were also assessed for the entire available follow-up period. RESULTS: The sample includes 121 patients (median age 72 years, IQR [53; 81]). The majority (74%, 89/121) received a ß-lactam antibiotic combined with aminoglycoside in 74% (89/121, median bi-therapy 5 days [1; 14]). Twenty-eight patients underwent surgery guided by ESC-guidelines (23%). The 12-month mortality rate was not significantly affected by antibiotic duration (4/40, 10% in the 4-week group vs 3/81, 3.7% in the 6-week group, p=0.34) or aminoglycoside usage (p=0.1). Similarly, there were no significant differences between the 2 treatment groups for secondary surgical procedures (7/40 vs 21/81, p=0.42), relapse or reinfection (1/40 vs 2/81 and 2/40 vs 5/81 respectively). CONCLUSIONS: Our study found no increased adverse outcomes associated with a 4-week antibiotic duration compared to the recommended 6-week regimen. Further randomized trials are needed to ascertain the optimal duration of treatment for streptococcal endocarditis.
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Endocarditis Bacteriana , Endocarditis , Prótesis Valvulares Cardíacas , Anciano , Humanos , Aminoglicósidos/uso terapéutico , Antibacterianos/uso terapéutico , Duración de la Terapia , Endocarditis/tratamiento farmacológico , Endocarditis/etiología , Endocarditis Bacteriana/microbiología , Prótesis Valvulares Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas/microbiología , Pronóstico , Reinfección , Estudios Retrospectivos , StreptococcusRESUMEN
BACKGROUND: The landscape of Pseudomonas infective endocarditis (IE) is evolving with the widespread use of cardiac implantable devices and hospital-acquired infections. This systematic review aimed to evaluate the emerging risk factors and outcomes in Pseudomonas IE. METHODS: A literature search was performed in major electronic databases (PubMed, Scopus, and Google Scholar) with appropriate keywords and combinations till November 2023. We recorded data for risk factors, diagnostic and treatment modalities. This study is registered with PROSPERO, CRD42023442807. RESULTS: A total of 218 cases (131 articles) were included. Intravenous drug use (IDUs) and prosthetic valve endocarditis (PVE) were major risk factors for IE (37.6% and 22%). However, the prosthetic valve was the predominant risk factor in the last two decades (23.5%). Paravalvular complications (paravalvular leak, abscess, or pseudoaneurysm) were described in 40 cases (18%), and the vast majority belonged to the aortic valve (70%). The mean time from symptom onset to presentation was 14 days. The incidence of difficult-to-treat resistant (DTR) pseudomonas was 7.4%. Valve replacement was performed in 57.3% of cases. Combination antibiotics were used in most cases (77%), with the aminoglycosides-based combination being the most frequently used (66%). The overall mortality rate was 26.1%. The recurrence rate was 11.2%. Almost half of these patients were IDUs (47%), and most had aortic valve endocarditis (76%). CONCLUSIONS: This review highlights the changing epidemiology of Pseudomonas endocarditis with the emergence of prosthetic valve infections. Acute presentation and associated high mortality are characteristic of Pseudomonas IE and require aggressive diagnostic and therapeutic approach.
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The long-term safety, efficacy, and outcomes of low-intensity anticoagulation for mechanical heart valves remain unclear. This study aimed to evaluate the long-term outcomes of low-intensity anticoagulation therapy after aortic valve replacement (AVR) with a mechanical prosthesis. This retrospective cohort study consulted medical records and conducted a questionnaire to investigate 519 patients who underwent single AVR with the St. Jude Medical bileaflet valve and were in sinus rhythm. All patients were followed up with an international normalized ratio (INR) target of 1.6-2.5, and their INR values were checked throughout the follow-up period. The survival rate, incidence of major adverse cardiac and cerebrovascular events (MACCE), and risk factors for cardiac death and MACCE were investigated. The total follow-up was 9793 patient-years, and the follow-up periods were 19.9 (standard deviation [SD]: 7.9) years. The mean INR was 2.03 (SD: 0.54). Survival rates from cardiac death were 93.6% in 20 years and 85.2% in 30 years. Advanced age ≥ 70 years was the only significant risk factor for cardiac death and MACCE, and the INR < 2.0 was not significant risk factor for MACCE including thromboembolism or bleeding events. Low-intensity anticoagulation with an INR of 1.6-2.5 for patients with sinus rhythm after AVR with a bileaflet mechanical valve is safe and effective, even over 30 years.
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Anticoagulantes , Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Humanos , Masculino , Femenino , Estudios Retrospectivos , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Anciano , Válvula Aórtica/cirugía , Factores de Riesgo , Persona de Mediana Edad , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Factores de Tiempo , Relación Normalizada Internacional , Estudios de Seguimiento , Diseño de Prótesis , Tasa de Supervivencia/tendencias , Tromboembolia/prevención & control , Tromboembolia/etiología , Tromboembolia/epidemiología , Incidencia , Complicaciones Posoperatorias/epidemiologíaRESUMEN
OBJECTIVE: Patients with bicuspid aortic valves (BAV) are at increased risk of infective endocarditis (IE). Information of the clinical presentation and the microbiology of BAV-associated IE, however, is limited. Therefore, our study aimed to characterise the clinical features native valve endocarditis (NVE) in the setting of BAV and compared them to patients with prosthetic valve endocarditis (PVE) following BAV replacement. METHODS: Adult patients with BAV or history of BAV with aortic valve replacement (AVR) and a definite or possible IE diagnosis within the Mayo Clinic Enterprise (USA) from January 2008 to December 2021, were included. BAV was confirmed by trans-oesophageal echocardiography. IE was defined according to the modified Duke criteria and only an initial episode was included. Statistical analyses were performed to compare clinical characteristics, microbiology, and IE complications. RESULTS: Overall, 161 patients with BAV and IE (NVE [n=60], 37.3%) and PVE [n=101, 62.7%) were included. Mean age±SD was 56.5±16.1 years, and 139 (86.3%) patients were males. PVE patients were older (p<0.01) and had a higher rate of hypertension (p<0.01), chronic heart failure (p<0.01), chronic kidney disease (p<0.01), and perivalvular abscess (p<0.01). BAV patients with NVE had a higher prevalence of isolated mitral valve IE (p<0.01), moderate to severe aortic valve regurgitation (p<0.01) and combined aortic with mitral valve IE (p<0.01). Streptococcus mitis was the most common pathogen in NVE (30.0%) while Staphylococcus aureus was the most common in PVE (15.8%). CONCLUSIONS: Patients with BAV are at risk of both NVE and PVE. Each syndrome has unique clinical features, including microbiologic findings, that should be appreciated in IE diagnosis and management.
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AIMS: Prosthetic valve endocarditis (PVE) is the most severe form of infective endocarditis associated with a high mortality rate. Whether PVE affects biological and mechanical aortic valves to the same extent remains controversial. This study aimed to compare the incidence of re-intervention because of PVE between bioprosthetic and mechanical valves. METHODS: Patients undergoing isolated surgical aortic valve replacement (AVR) or combined AVR in a single cardiac surgery centre between January 1998 and December 2019 were analysed. All patients who underwent re-intervention because of PVE were identified. The primary endpoint was the rate of explants. Freedom from re-intervention and variables associated with re-intervention were analysed using Cox regression analysis including correction for competing risk. RESULTS: During the study period, 5,983 aortic valve prostheses were implanted, including 3,620 biological (60.5%) and 2,363 mechanical (39.5%) prostheses. The overall mean follow-up period was 7.3±5.3 years (median, 6.5; IQR 2.9-11.2 years). The rate of re-intervention for PVE in the biological group was 1.5% (n=54) compared with 1.7% (n=40) in the mechanical group (p=0.541). Cox regression analysis revealed that younger age (HR 0.960, 95% CI 0.942-0.979; p<0.001), male sex (HR 2.362, 95% CI 1.384-4.033; p=0.002), higher creatinine (HR 1.002, 95% CI 0.999-1.004; p=0.057), and biological valve prosthesis (HR 2.073, 95% CI 1.258-3.414; p=0.004) were associated with re-intervention for PVE. After correction for competing risk of death, biological valve prosthesis was significantly associated with a higher rate of re-intervention for PVE (HR 2.011, 95% CI 1.177-3.437; p=0.011). CONCLUSIONS: According to this single-centre, observational, retrospective cohort study, AVR using biological prosthesis is associated with re-intervention for PVE compared to mechanical prosthesis. Further investigations are needed to verify these findings.
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Endocarditis Bacteriana , Endocarditis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Humanos , Masculino , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Endocarditis Bacteriana/complicaciones , Estudios Retrospectivos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Endocarditis/epidemiología , Endocarditis/etiología , Endocarditis/cirugíaRESUMEN
BACKGROUND: The microbial etiology of prosthetic valve infective endocarditis (PVE) can be difficult to identify. Our aim was to investigate the benefit of molecular imaging technique fluorescence in situ hybridization (FISH) combined with 16S rRNA-gene polymerase chain reaction (PCR) and sequencing (FISHseq) for the analysis of infected prosthetic heart valves. METHODS: We retrospectively evaluated the diagnostic outcome of 113 prosthetic valves from 105 patients with suspected PVE, treated in 2003-2013 in the Department of Cardiac Surgery, Charité University Medicine Berlin. Each prosthetic valve underwent cultural diagnostics and was routinely examined by FISH combined with 16S rRNA gene PCR and sequencing. We compared classical microbiological culture outcomes (blood and valve cultures) with FISHseq results and evaluated the diagnostic impact of the molecular imaging technique. RESULTS: Conventional microbiological diagnostic alone turned out to be insufficient, as 67% of preoperative blood cultures were noninformative (negative, inconclusive, or not obtained) and 67% of valve cultures remained negative. FISHseq improved the conventional cultural diagnostic methods in PVE in 30% of the cases and increased diagnostic accuracy. Of the valve culture-negative PVE cases, FISHseq succeeded in identifying the causative pathogen in 35%. CONCLUSIONS: FISHseq improves PVE diagnostics, complementing conventional cultural methods. In addition to species identification, FISH provides information about the severity of PVE and state of the pathogens (eg, stage of biofilm formation, activity, and localization on and within the prosthetic material). As a molecular imaging technique, FISHseq enables the unambiguous discrimination of skin flora as contaminant or infectious agent.
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Endocarditis Bacteriana , Endocarditis , Prótesis Valvulares Cardíacas , Infecciones Relacionadas con Prótesis , Humanos , Endocarditis Bacteriana/microbiología , Prótesis Valvulares Cardíacas/efectos adversos , Estudios Retrospectivos , Hibridación Fluorescente in Situ , ARN Ribosómico 16S/genética , Infecciones Relacionadas con Prótesis/microbiología , Endocarditis/etiología , Imagen MolecularRESUMEN
Cardiac positron emission tomography (PET) imaging has established themselves firmly as excellent and reliable functional imaging modalities in assessment of the spectrum of coronary artery disease. With the explosion of technology advances and the dream of flow quantification now a reality, the value of PET is now well realized. Cardiac PET has proved itself as precise imaging modality that provides functional imaging of the heart in addition to anatomical imaging. It has established itself as one of the best available techniques for evaluation of myocardial viability. Hybrid PET/computed tomography provides simultaneous integration of coronary anatomy and function with myocardial perfusion and metabolism, thereby improving characterization of the dysfunctional area and chronic coronary artery disease. The availability of quantitative myocardial blood flow evaluation with PET provides additional prognostic information and increases diagnostic accuracy in the management of patients with coronary artery disease. Hybrid imaging seems to hold immense potential in optimizing management of cardiovascular diseases and furthering clinical research.
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Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Imagen de Perfusión Miocárdica , Humanos , Imagen de Perfusión Miocárdica/métodos , Corazón , Tomografía de Emisión de Positrones/métodosRESUMEN
BACKGROUND: Our objective was to evaluate in patients with prosthetic valve endocarditis (PVE) treated conservatively, the prognostic value of white blood cell (WBC) signal intensity on SPECT and to describe the evolution of the WBC signal under antibiotics. METHODS: Patients with PVE treated conservatively and positive WBC-SPECT imaging were identified retrospectively. Signal intensity was classified as intense if equal to or higher, or mild if lower, than the liver signal. Clinical, biological, imaging and follow-up information were collected from medical files. RESULTS: Among 47 patients, WBC signal was classified as intense in 10 patients and as mild, in 37. The incidence of the primary composite endpoint (death, late cardiac surgery, or relapse) was significantly higher in patients with intense vs. mild signal (90% vs. 11%). Twenty-five patients underwent a second WBC-SPECT imaging during follow-up. The prevalence of WBC signal decreased progressively from 89% between 3 and 6 weeks to 42% between 6 and 9 weeks and 8% more than 9 weeks after initiation of antibiotics. CONCLUSIONS: In patients with PVE treated conservatively, intense WBC signal was associated with poor outcome. WBC-SPECT imaging appears as an interesting tool for risk stratification and to monitor locally the efficacy of antibiotic treatment.
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Endocarditis Bacteriana , Endocarditis , Prótesis Valvulares Cardíacas , Infecciones Relacionadas con Prótesis , Humanos , Estudios de Seguimiento , Estudios Retrospectivos , Prótesis Valvulares Cardíacas/efectos adversos , Endocarditis/diagnóstico por imagen , Endocarditis/tratamiento farmacológico , Endocarditis/etiología , Pronóstico , Tomografía Computarizada de Emisión de Fotón Único , Leucocitos , Antibacterianos/uso terapéutico , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Infecciones Relacionadas con Prótesis/etiologíaRESUMEN
Since the beginning of the SARS-CoV-2 (COVID-19) pandemic, correlation of venous thromboembolism (VTE) and COVID-19 infection has been well established. Increased inflammatory response in the setting of COVID-19 infection is associated with VTE and hypercoagulability. Venous and arterial thrombotic events in COVID-19 infection have been well documented; however, few cases have been reported involving cardiac valve prostheses. In this review, we present a total of eight cases involving COVID-19-related prosthetic valve thrombosis (PVT), as identified in a systematic review. These eight cases describe valve position (mitral versus aortic) and prosthesis type (bioprosthetic versus mechanical), and all cases demonstrate incidents of PVT associated with simultaneous or recent COVID-19 infection. None of these eight cases display obvious non-adherence to anticoagulation; five of the cases occurred greater than three years after the most recent valve replacement. Our review offers insights into PVT in COVID-19 infected patients including an indication for increased monitoring in the peri-infectious period. We explore valve thrombosis as a mechanism for prosthetic valve failure. We describe potential differences in antithrombotic strategies that may offer added antithrombotic protection during COVID-19 infection. With the growing population of valve replacement patients and recurring COVID-19 infection surges, it is imperative to explore relationships between COVID-19 and PVT.
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COVID-19 , Enfermedades de las Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Trombosis , Tromboembolia Venosa , Humanos , Fibrinolíticos , Tromboembolia Venosa/complicaciones , COVID-19/complicaciones , SARS-CoV-2 , Enfermedades de las Válvulas Cardíacas/complicaciones , Prótesis Valvulares Cardíacas/efectos adversos , Trombosis/complicaciones , Válvula AórticaRESUMEN
Evaluation of mechanical prosthetic valve function is based on echocardiography, but adequate assessment of leaflet motion is limited by acoustic shadowing. Cinefluoroscopy is a standard method to assess leaflet motion, while computed tomography (CT) has been suggested as an alternative. We sought to compare the feasibility of leaflet motion assessment by cinefluoroscopy vs. CT. In 35 prospectively enrolled patients, leaflet motion was assessed in 43 bileaflet mechanical prostheses (29 mitral and 14 aortic) by cinefluoroscopy and non-contrast CT. Assessment was considered feasible when the 'in profile' projection (with the radiographic beam parallel to both the valve ring plane and the tilting axis of discs) could be achieved. Overall feasibility of fluoroscopic assessment was 74% (mitral, 66% vs. aortic, 93%; p = 0.071), while feasibility of CT assessment was 100% (p = 0.003). Among prostheses with unfeasible fluoroscopic assessment, CT suggested an extreme C-arm angulation to achieve the "in profile" projection (RAO: 76.0 ± 5.8°, LAO: 122.7 ± 32.5°, CRA: 51.4 ± 16.0°, CAU: 57.0 ± 18.2°). Among prostheses with feasible assessment by both techniques, fluoroscopy and CT yielded similar opening and closing angles (intraclass correlation coefficient, 0.959-0.998) with lower irradiation with CT as compared with fluoroscopy (26.2[21.1-29.3] vs. 289[179-358] mGy, p < 0.001). While CT scan took 8.7 ± 0.5 s, fluoroscopy required 2.64 ± 1.56 min to achieve and record the "in profile" projection. Non-contrast CT provides a higher feasibility and a quicker evaluation of mechanical prosthetic valve leaflet motion with less irradiation than fluoroscopy, especially in mitral valve position.
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Prótesis Valvulares Cardíacas , Humanos , Válvula Aórtica/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Válvula Mitral/diagnóstico por imagen , EcocardiografíaRESUMEN
Mitral aortic intervalvular fibrosa or aorto-mitral curtain is a fibrous avascular skeletal structure located between the anterior leaflet of the mitral valve and the non-coronary and left coronary cusps of the aortic valve. Mitral and aortic valve endocarditis are rarely accompanied by mitral aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula of the aorta. Pseudoaneurysm of mitral aortic intervalvular fibrosa is a fatal complication that can occur after valvular surgery, valvular endocarditis, or blunt trauma. In this article, reconstructive surgical management with the Commando technique of a case who developed mitral-aortic intervalvular fibrosa pseudoaneurysm to left atrial fistula after aortic and mitral prosthetic valve endocarditis is described. The important feature of this article is that it is a first in the literature as it is accompanied by persistent left superior vena cava.
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Aneurisma Falso , Fibrilación Atrial , Endocarditis Bacteriana , Endocarditis , Prótesis Valvulares Cardíacas , Humanos , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/diagnóstico por imagen , Endocarditis Bacteriana/cirugía , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/cirugía , Aneurisma Falso/complicaciones , Vena Cava Superior , Fibrilación Atrial/complicaciones , Prótesis Valvulares Cardíacas/efectos adversos , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Endocarditis/complicaciones , AortaRESUMEN
New cardiovascular imaging technologies have strongly influenced the diagnosis of bacterial endocarditis [infective endocarditis (IE)]. The clinical presentation of IE is polymorphic, which explains the difficulty of diagnosis and the delay in treatment. Symptoms such as fever, chills, loss of appetite and weight, and embolic phenomena strongly support the diagnosis of endocarditis, but are not always present, particularly in elderly or immuno-compromised patients. Moreover, subtle symptoms in patients at high risk for the development of IE, such as those with prosthetic valves or intracardiac devices, patients with congenital heart disease, and drug addicts should lead to the suspicion that a diagnosis of IE is highly probable. In this review, we will focus on the diagnosis of complex IE in native valves and prosthetic valves.
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Stroke is a leading cause of mortality and disability, and cardiac embolism accounts for one-third of all ischaemic strokes. Thirty per cent of strokes are cryptogenic. In this setting, echocardiography is essential in the diagnosis, treatment, and prevention of embolic stroke of undetermined source since it is a widely available, safe, and inexpensive tool. Transthoracic echocardiography and transoesophageal echocardiography, furthermore, are proven to change therapeutic management leading to initiation of anti-coagulation, anti-microbial therapy, patent foramen ovale (PFO) closure, or cardiac tumour resection. The most common cardioembolic sources include left atrial appendage thrombus, left ventricular thrombus, vegetations in endocarditis, paradoxical embolization in PFO, prosthesis thrombosis, and intracardiac tumours. Although the presence of a cardioembolic source only represents a risk factor for an ischaemic stroke, it could not assure the certain or the unique cause of the event. The purpose of this review is to underline the importance of echocardiography and overview the main sources of cardiac embolism and the echocardiographic features.
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Background and Objectives: To evaluate the early and long-term results of surgical treatment of isolated mitral native and prosthetic valve infective endocarditis. Materials and Methods: All patients undergoing mitral valve repair or replacement for infective endocarditis at our institution between January 2001 and December 2021 were included in the study. The preoperative and postoperative characteristics and mortality of patients were retrospectively reviewed. Results: A total of 130 patients, 85 males and 45 females, with a median age of 61 ± 14 years, underwent surgery for isolated mitral valve endocarditis during the study period. There were 111 (85%) native and 19 (15%) prosthetic valve endocarditis cases. Fifty-one (39%) patients died during the follow-up, and the overall mean patient survival time was 11.8 ± 0.9 years. The mean survival time was better in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (12.3 ± 0.9 years vs. 8 ± 1.4 years; p = 0.1), but the difference was not statistically significant. Patients who underwent mitral valve repair had a better survival rate compared to patients who had mitral valve replacement (14.8 ± 1.6 vs. 11.3 ± 1 years; p = 0.06); however, the difference was not statistically significant. Patients who underwent mitral valve replacement with a mechanical prosthesis had a significantly better survival rate compared to patients who received a biological prosthesis (15.6 ± 1.6 vs. 8.2 ± 0.8 years; p < 0.001). Patients aged ≤60 years had significantly better survival compared to patients aged >60 years (17.1 ± 1.1 vs. 8.2 ± 0.9; p < 0.001). Multivariate analysis showed that the patient's age >60 years at the time of surgery was an independent risk factor for mortality, while mitral valve repair was a protective factor. Eight (7%) patients required reintervention. Freedom from reintervention was significantly higher in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (19.3 ± 0.5 vs. 11.5 ± 1.7 years; p = 0.04). Conclusions: Surgery for mitral valve endocarditis is associated with considerable morbidity and mortality. The patient's age at the time of surgery represents an independent risk factor for mortality. Mitral valve repair should be the preferred choice whenever possible in suitable patients affected by infective endocarditis.
Asunto(s)
Endocarditis Bacteriana , Endocarditis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Masculino , Femenino , Humanos , Persona de Mediana Edad , Anciano , Endocarditis Bacteriana/cirugía , Válvula Mitral/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Prótesis Valvulares Cardíacas/efectos adversos , Endocarditis/cirugíaRESUMEN
Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis.
Asunto(s)
Endocarditis Bacteriana , Endocarditis , Enfermedades de las Válvulas Cardíacas , Humanos , Válvula Mitral/cirugía , Estudios Retrospectivos , Nivel de Atención , Endocarditis/cirugíaRESUMEN
BACKGROUND: Heart valve replacement surgery with mechanical or biological prostheses entails a risk of thromboembolism and bleeding complications. OBJECTIVE: To determine the complications related to complementary anticoagulation therapy and the probability of risk. METHODS: One-hundred and sixty-three patients who underwent heart valve replacement between 2002 and 2016 with either mechanical or biological prostheses, and who received vitamin K antagonists after hospital discharge, were studied. Anticoagulation therapy was categorized into optimal and non-optimal according to INR values prior to the development of complications. Patients with comorbidities and other risk factors for thrombosis and/or bleeding were excluded. RESULTS: In total, 68.7 % of patients received mechanical prostheses, and 31.3 %, biological prostheses (p ≤ 0.001); 25.2 % experienced the complications that motivated the study (p ≤ 0.001), which were hemorrhagic in 48.8 %, thromboembolic in 26.8 %, and of both types in 24.4 % (relative risk = 4.229). Among the patients with complications, 95.1 % received mechanical prostheses, and 4.9 %, biological (p = 0.005); non-optimal INR was identified in 49.7 % (p ≤ 0.001). CONCLUSIONS: Given the high risk of thromboembolic and hemorrhagic complications, valve prostheses must be carefully chosen, and care priorities should include prevention and follow-up, especially in those patients who require anticoagulation therapy.
ANTECEDENTES: El reemplazo valvular por prótesis mecánicas o biológicas implica riesgo de tromboembolismo y complicaciones hemorrágicas. OBJETIVO: Determinar las complicaciones relacionadas con la terapia de anticoagulación complementaria y la probabilidad de riesgo en pacientes portadores de prótesis valvulares del corazón. MÉTODOS: Se estudiaron 163 pacientes entre 2002 y 2016, portadores de prótesis mecánicas y biológicas, quienes recibieron antagonistas de la vitamina K posterior al egreso hospitalario. La terapia de anticoagulación se categorizó en óptima y no óptima conforme a los valores de INR previos a las complicaciones. Fueron excluidos los pacientes con comorbilidades y otros factores de riesgo de trombosis y/o sangrado. RESULTADOS: a 68.7 % de los pacientes se les colocó prótesis mecánica y a 31.3 %, biológica (p ≤ 0.001); 25.2 % presentó las complicaciones motivo de estudio (p ≤ 0.001), hemorrágicas en 48.8 %, tromboembólicas en 26.8 % y de ambos tipos en 24.4 % (riesgo relativo = 4.229); a 95.1 % de los pacientes con complicaciones se les colocó prótesis mecánica y a 4.9 %, biológica (p = 0.005); 49.7 % presentó INR no óptimo (p ≤ 0.001). CONCLUSIONES: Ante riesgo alto de complicaciones tromboembólicas y hemorrágicas, la elección de las prótesis valvulares, la prevención y el seguimiento son prioridades, principalmente en quienes requieren terapia de anticoagulación.