Aortic regurgitation management: a systematic review of clinical practice guidelines and recommendations.

Guidelines for the diagnosis and management of aortic regurgitation (AR) contain recommendations that do not always match. We systematically reviewed clinical practice guidelines and summarized similarities and differences in the recommendations as well as gaps in evidence on the management of AR. We searched MEDLINE and Embase (1 January 2011 to 1 September 2021), Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed as assessed by the Appraisal of Guidelines for Research and Evaluation II tool. Three guidelines met our inclusion criteria. There was consensus on the definition of severe AR and use of echocardiography and of multimodality imaging for diagnosis, with emphasis on comprehensive assessment by the heart valve team to assess suitability and choice of intervention. Surgery is indicated in all symptomatic patients and aortic valve replacement is the cornerstone of treatment. There is consistency in the frequency of follow-up of patients, and safety of non-cardiac surgery in patients without indications for surgery. Discrepancies exist in recommendations for 3D imaging and the use of global longitudinal strain and biomarkers. Cut-offs for left ventricular ejection fraction and size for recommending surgery in severe asymptomatic AR also vary. There are no specific AR cut-offs for high-risk surgery and the role of percutaneous intervention is yet undefined. Recommendations on the treatment of mixed valvular disease are sparse and lack robust prospective data.

Tricuspid regurgitation management: a systematic review of clinical practice guidelines and recommendations.

Tricuspid regurgitation (TR) is a highly prevalent condition and an independent risk factor for adverse outcomes. Multiple clinical guidelines exist for the diagnosis and management of TR, but the recommendations may sometimes vary. We systematically reviewed high-quality guidelines with a specific focus on areas of agreement, disagreement, and gaps in evidence. We searched MEDLINE and EMBASE (1 January 2011 to 30 August 2021), the Guidelines International Network International, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed (as assessed by the Appraisal of Guidelines for Research and Evaluation II tool). Three guidelines were finally retained. There was consensus on a TR grading system, recognition of isolated functional TR associated with atrial fibrillation, and indications for valve surgery in symptomatic vs. asymptomatic patients, primary vs. secondary TR, and isolated TR forms. Discrepancies exist in the role of biomarkers, complementary multimodality imaging, exercise echocardiography, and cardiopulmonary exercise testing for risk stratification and clinical decision-making of progressive TR and asymptomatic severe TR, management of atrial functional TR, and choice of transcatheter tricuspid valve intervention (TTVI). Risk-based thresholds for quantitative TR grading, robust risk score models for TR surgery, surveillance intervals, population-based screening programmes, TTVI indications, and consensus on endpoint definitions are lacking.

Myocardial ischaemia as a result of external coronary compression from infective aortic root aneurysm: atypical presentation of prosthetic valve endocarditis.

SummaryThis case describes an unusual presentation of prosthetic valve endocarditis (PVE): an acute coronary syndrome. A 67-year-old male presented with cardiac sounding chest pain on a background of a short history of night sweats, weight loss and general malaise. Four months previously, he had undergone bio-prosthetic aortic valve replacement for severe aortic stenosis and single vessel bypass grafting of the obtuse marginal. Whilst having chest pain, his ECG showed infero-lateral ST depression. Early coronary angiography revealed a new right coronary artery (RCA) lesion that was not present prior to his cardiac surgery. Using multi-modality cardiac imaging, the diagnosis of PVE was made. An aortic root abscess was demonstrated that was causing external compression of the RCA. LEARNING POINTS: PVE accounts for up to 20% of all cases of infective endocarditis.High clinical suspicion and early blood cultures before empirical antibiotics are key as the presentation of PVE can often be atypical.PVE rarely presents as an acute coronary syndrome. Potential mechanisms by which PVE may result in an ACS include coronary embolization, obstruction of coronary ostia by a large mobile vegetation and external coronary artery compression from an infective aneurysms/abscess.Repeat cardiac surgery is often required for high-risk PVE such as those caused by staphylococcal infection or severe prosthetic dysfunction.

76-year-old gentlemen with primary cardiac lymphoma presenting as acute coronary syndrome and atrioventricular block.

We report the case of an immunocompetent patient who presented with symptoms suggestive of acute coronary syndrome and was found to be in complete heart block. He re-presented within 2 months with worsening breathlessness and investigations confirmed infiltrative cardiac disease. We describe here an uncommon presentation of primary cardiac lymphoma as acute coronary syndrome and atrioventricular block.

Proteus endocarditis in an intravenous drug user.

Infective endocarditis (IE) is a life-threatening condition with adverse consequences and increased mortality, despite improvements in treatment options. Diagnosed patients usually require a prolonged course of antibiotics, with up to 40-50% requiring surgery during initial hospital admission. We report a case of a 42-year-old intravenous drug user who presented feeling generally unwell, with lethargy, rigours, confusion and a painful swollen right leg. He was subsequently diagnosed with Proteus mirabilis endocarditis (fulfilling modified Duke criteria for possible IE) and deep vein thrombosis (DVT). He was successfully treated with single antibiotic therapy without needing surgical intervention or requiring anticoagulation for his DVT. Proteus endocarditis is extremely uncommon, with a limited number of case reports available in the literature. This case illustrates how blood cultures are invaluable in the diagnosis of IE, especially that due to unusual microorganisms. Our case also highlights how single antibiotic therapy can be effective in treating Proteus endocarditis.

Using coronary artery calcification combined with pretest clinical risk assessment as a means of determining investigation and treatment in patients presenting with chest pain in a rural setting.

462 patients presenting with chest pain to a rural district general hospital underwent calcium scoring and pretest clinical risk assessment in order to stratify subsequent investigations and treatment was retrospectively reviewed. The patients were followed up for two years and further investigations and outcomes recorded. Of the 206 patients with zero calcium score, 132 patients were immediately discharged from cardiac follow-up with no further investigation on the basis of their calcium score, low pretest risk of coronary artery disease, and no significant incidental findings. After further tests, 267 patients were discharged with no further cardiac therapy, 88 patients were discharged with additional medical therapy, and 19 patients underwent coronary artery by-pass grafting or percutaneous intervention. 164 patients with incidental findings on the chest CT (computed tomography) accompanying calcium scoring were reviewed, of which 88 patients underwent further tests and follow-up for noncardiac causes of chest pain. The correlations between all major risk factors and calcium scores were weak except for a combination of diabetes and hypertension in the male gender (P = 0.012), The use of calcium scoring and pretest risk appeared to reduce the number of unnecessary cardiac investigations in our patients: however, the calcium scoring test produced a high number of incidental findings on the associated CT scans.