Review of surgical prosthetic paravalvular leaks: diagnosis and catheter-based closure.

Paravalvular leak (PVL) is an uncommon yet serious complication associated with surgical prosthetic valve implantation. Paravalvular leak can have significant clinical consequence such as congestive heart failure, haemolytic anaemia, and infective endocarditis. Recently, transcatheter therapy has been applied to the treatment of this disorder with reasonable procedural and clinical success. This review discusses the current state of PVLs, the utilization of multi-modality imaging in their diagnosis and treatment, and the available therapeutic options. Further aim of this review is to examine transcatheter therapy of PVLs including the principles, outcomes, and procedural-related complications.

High prevalence of pulmonary arterial hypertension in a cohort of asymptomatic HIV-infected patients.

HIV infection is considered a risk factor for the development of pulmonary arterial hypertension (PAH) and the estimated prevalence of PAH in developed countries is 0.5%. The aim of this study was to determine the prevalence of PAH in a cohort of HIV-infected patients and the related factors. We undertook an observational study of a consecutive cohort of asymptomatic HIV-infected patients. Data were recorded about factors of cardiovascular interest and factors related to HIV infection. All the patients underwent a transthoracic echocardiogram (Vivid S6, GE Healthcare). PAH was considered to be a pulmonary arterial systolic pressure (PASP) >40 mm Hg. The study included 194 patients (85.2% men) with a mean age of 47.0 years, 94% of whom were on antiretroviral therapy (ART). The mean CD4 lymphocyte count was 495/mm(3). The mean duration of HIV infection was 131.5 months, and 28.4% had experienced an AIDS event. PAH was present in five patients (2.6%) and 14 were in the gray zone (PASP of 36-40 mm Hg). These five patients were men, the route of transmission was homosexual, and they were all on ART. They were also older than the patients without PAH (57.7 vs. 46.4 years, p=0.02) and had been on ART for longer (180.0 vs. 92.5 months; p=0.01). No association was found with any of the other parameters. The prevalence of PAH in this cohort of patients was greater than in other published series. The only associations found were with older age and longer ART time.

Echocardiographic abnormalities and associated factors in a cohort of asymptomatic HIV-infected patients.

HIV patients have been reported to have a greater prevalence of echocardiographic abnormalities. We aimed to determine the prevalence of these abnormalities and their associated factors. This was an observational study of a cohort of asymptomatic HIV patients. Data were recorded on factors of cardiovascular interest and those related to HIV infection. All the subjects underwent a transthoracic echocardiogram. The study included 196 patients, 85.2% men, mean age 46.4 years, with a mean duration of HIV infection of 123.8 months and 27.6% with AIDS. Of the patients, 94.4% were on antiretroviral therapy and 92.5% of these had an undetectable viral load. The mean CD4 cell count was 544/mm(3). The following echocardiographic abnormalities were found: left ventricular (LV) hypertrophy 28.6%, LV diastolic dysfunction 19.9%, left atrial (LA) dilatation 7.7%, right ventricular (RV) systolic dysfunction 6.1%, pulmonary hypertension 2.6%, RV dilatation 2%, and (LV) systolic dysfunction 1%. LV hypertrophy was associated with diabetes mellitus (OR 5.3, 95% CI 1.8-15.3; p=0.001), LV diastolic dysfunction with age (OR for each extra 5 years 4.4, 95% CI 4.2-4.6; p=0.0001), obesity (OR 4.07, 95% CI 1.6-10.0; p=0.02), alcohol consumption (OR 2.5, 95% CI 1.07-6.2; p=0.03) and lower CD4 cell count (OR for each 10 CD4 cells less 10.02, 95% CI 10.00-10.04; p=0.008), and RV systolic dysfunction with hypertension (OR 5.4, 95% CI 1.6-18.2; p=0.005). Echocardiographic abnormalities in HIV patients were common, especially LV hypertrophy and diastolic dysfunction. Prospective comparative studies involving the general population are needed to determine the prevalence of HIV infection and its treatment in these abnormalities.

Prevalence and factors associated with a prolonged QTc interval in a cohort of asymptomatic HIV-infected patients.

We aimed to determine the prevalence of a prolonged QTc interval in HIV-infected patients and its related factors through an observational study of a cohort of asymptomatic HIV-infected outpatients. All patients underwent a standard 12-lead electrocardiogram and a transthoracic echocardiogram. Prolonged QTc was considered if it was >440 ms in men and >450 ms in women. Epidemiological, clinical, and laboratory data were collected and the patients completed a questionnaire about cardiovascular risk factors. The analysis of the potential risk factors for prolonged QTc was done by multivariate logistic regression. The study included 194 patients, 84% men, with a mean age of 46.3 years. The mean duration of HIV infection was 122.6 months and 27.8% had AIDS. Antiretroviral therapy was being taken by 185 (96.4%) patients, and 92.4% of them had an undetectable viral load. The mean CD4 lymphocyte count was 553/mm(3). A total of 24 (12.4%) patients had a prolonged QTc interval, with a mean QTc of 456 ms. The factors associated with a prolonged QTc were hyperlipidemia (OR 3.7, 95% CI: 1.3-10.3; p=0.01) and diastolic dysfunction (OR 6.7, 95% CI: 2.4-18.3; p=0.0001), while the use of atazanavir was associated with a lower likelihood of having a prolonged QTc (OR 0.11, 95% CI: 0.02-0.5; p=0.008). A prolonged QTc syndrome was not uncommon in this cohort of asymptomatic HIV-infected patients with good immunovirological control. It was associated with hyperlipidemia and diastolic dysfunction. The use of atazanavir, compared with other protease inhibitors, was associated with a lower likelihood of having a prolonged QTc.

Aortoesophageal fistula: an uncommon complication after stent-graft repair of an aortic thoracic aneurysm.

OBJECTIVES: To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. METHODS: We analyze a case of AEF as a late complication of stent-graft repair of a thoracic aortic aneurysm in a 74-year-old male. We also include a discussion on alternatives of treatment based on a review of the literature currently available in MEDLINE. RESULTS: This patient was admitted to our hospital because of constitutional symptoms. The diagnosis was established by computed tomography and upper gastrointestinal endoscopy. The patient died 50 days after admission. CONCLUSIONS: AEF is a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Conservative treatment is often associated with fatal results.

Community-acquired bacteremia and acute cholecystitis due to Enterobacter cloacae: a case report.

INTRODUCTION: Enterobacter cloacae is responsible for 65-75% of all Enterobacter infections, bacteremia being the most common syndrome. The majority of infections are nosocomially acquired and in patients with predisposing factors. CASE PRESENTATION: We present a case of E. cloacae bacteremia secondary to acute cholecystitis in a 60-year-old man with recent diagnosis of cholelithiasis. The diagnosis was established with abdominal echography and positive blood and biliary cultures. The patient was managed successfully with cholecystectomy and antibiotic therapy. CONCLUSION: The peculiarity of our case is the development of community-acquired bacteremia due to E. cloacae with a clear infectious focus, as a single agent isolated in several blood cultures, in a patient without severe underlying diseases, prior antimicrobial use or previous hospital admission. Although the majority of Enterobacter spp. infections are nosocomially acquired, primary bacteremia being the most common syndrome, these pathogens may also be responsible for community-acquired cases. Patients without predisposing factors may also be affected.