Heart transplantation as salvage treatment of intractable infective endocarditis.

BACKGROUND: For infective endocarditis (IE) with extensive perivalvular lesions or end-stage cardiac failure, heart transplantation (HT) may be the last resort. METHODS: We retrospectively collected all cases of HT for IE within the International Collaboration on Endocarditis (ICE) network. RESULTS: Between 1991 and 2021, 20 patients (5 women, 15 men), median age 50 years [interquartile range, 29-61], underwent HT for IE in Spain (n = 9), France (n = 6), Switzerland (n = 2), Colombia, Croatia, and USA (n = 1). IE affected prosthetic (n = 10), and native valves (n = 10), primarily aortic (n = 11) and mitral (n = 6). The main pathogens were oral streptococci (n = 8), Staphylococcus aureus (n = 5), and Enterococcus faecalis (n = 2). The major complications included heart failure (n = 18), peri-annular abscess (n = 10), and prosthetic valve dehiscence (n = 4). Eighteen patients had previous cardiac surgery for this episode of IE, and four were on circulatory support before HT (left ventricular assist-device and extra-corporeal membrane oxygenation, 2 patients each). The median time interval between first symptoms of IE and HT was 44.5 days [22-91.5]. The main post-HT complication was acute rejection (n = 6). Seven patients died (35%), four during the first month post-HT. Thirteen (81%) of the 16 patients discharged from the hospital survived with a median follow-up of 35.5 months [4-96.5] after HT, and no relapse of IE. CONCLUSIONS: IE is not an absolute contraindication for HT: Our case series and the literature review support that HT may be considered as a salvage treatment in highly-selected patients with intractable IE.

Quality of life 10 years after cardiac surgery in adults: a long-term follow-up study.

We have read the article titled "Quality of life 10 years after cardiac surgery in adults: a long-term follow-up study " by Perrotti A. et al. published in your distinguished journal with great interest. Unfortunately, we found few errors in this article.

Primary Left Atrial Angiosarcoma Presenting as Acute Coronary Syndrome.

Primary cardiac neoplasms are extremely rare and often overlooked as differential diagnosis. Angiosarcomas are the most common primary malignant neoplasms of the heart often with nonspecific symptoms. We present a 43-year-old woman admitted to our hospital with chest pain and inferoposterolateral myocardial infarction. Coronary angiography indicated the distal occlusion of the left circumflex artery. Transthoracic and transoesophagic echocardiography revealed a mass in the left atrium with probable myocardial infiltration and vascularisation. The mass in the left atrium was removed by surgical resection, and histopathology confirmed angiosarcoma. We emphasize the pivotal role of transthoracic and transoesophageal echocardiography in evaluating even rare differential diagnosis of acute coronary syndrome as cardiac neoplasms.

Dilemma in clinical diagnosis of right ventricular masses.

Detection of an intracardiac mass always represents a clinical challenge. We present a 61-year-old female patient with symptoms of New York Heart Association class III. Two-dimensional transthoracic echocardiography revealed a hypoechogenic mass in the cavity of the dilated right ventricle (RV). Cardiac MRI described a pathologic structure of the RV free wall with pedunculated tumor in its cavity. Three months later, on a repeated echocardiography, there were three individual masses. The patient underwent surgery and the pathohistologic report demonstrated thrombotic masses. During the postoperative period, after reviewing all medical records, the conclusion was arrhythmogenic RV cardiomyopathy. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:362-369, 2017.

The Role of Standard Echocardiographic Parameters in Endomyocardial Biopsy Proven Cardiac Amyloidosis.

Primary light-chain (AL) amyloidosis is a plasma cell dyscrasia associated with the deposition of immunoglobulin-derived amyloid in multiple organs. In the heart, this results in an infiltrative cardiomyopathy, with increased left ventricular wall thickness, normal or decreased left ventricular (LV) cavity size and congestive heart failure. Cardiac involvement is a major determinant of prognosis of AL amyloidosis. We report a patient with cardiac amyloidosis proven by cardiac biopsy, and aim to point out at transthoracic echocardiography as the hallmark of diagnostics. Echocardiography revealed increased LV thickness at 20mm, impaired LV ejection fraction (EF) at 35%, enlarged atria, transmitral deceleration time at 156 ms and increased E/A ratio at 4.25. Early diagnosis and intervention can have a significant impact on the patient's response to treatment, especially when the underlying condition involves a malignancy or infiltrative disorder. Standard transthoracic echocardiography as a noninvasive diagnostic tool is valuable and has a significant role in diagnosis and prognosis.

Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke.

BACKGROUND: The timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities. METHODS: Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates. RESULTS: Of the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650). CONCLUSIONS: There is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes.

Pulmonary valve papillary fibroelastoma diagnosed by echocardiography: a case report.

Papillary fibroelastomas (PFEs) are rare cardiac valve tumours with reported incidence of <0.03% according to autopsy studies. Among them, pulmonary valve PFEs are extremely rare. With wider use of echocardiography, they are being increasingly recognized premortem. We describe a case of a 32-year-old Caucasian woman with PFE of pulmonic valve diagnosed by echocardiography. The patient underwent surgery due to high mobility of the tumour and high risk of embolic complications. The surgery was done with complete tumour resection and total preservation of valve function. This case report discusses diagnostics of PFEs, their characteristic echocardiographic and histological features, and possible complications and suggests treatment options in this rare cardiac tumour.

Infective endocarditis of aortic valve during pregnancy: a case report.

Infective endocarditis during pregnancy is uncommon but very serious. A 31-year-old woman in the 36th week of second pregnancy was admitted to a hospital because of fever, weakness, chest pain, painful skin over her right leg and dyspnea. Transthoracic echocardiography showed aortic valve vegetation and severe aortic regurgitation. Transesophageal echocardiography revealed a 18 mmx6 mm mobile vegetation, attached to the right coronary cusp. Emergency cesarean section followed with a delivery of a healthy baby. Cardiopulmonary bypass with subsequent aortic replacement with bioprosthesis was initiated immediately after cesarean section. Early echocardiographic examination and 6 months after surgery revealed normal function of aortic valve bioprosthesis and normal LV function. Clinical recognition and early echocardiographic diagnosis followed urgent simultaneous cesarean section and aortic valve replacement was lifesaving for both mother and fetus.

[Unusual presentation of an right atrial myxoma]. / Neobicna prezentacija miksoma desnog atrija.

We report a case of a right atrial myxoma initially presenting as an acute anteroseptal MI. A 46-year-old man has been admitted to our ICU with chest pain started five hours before. The initial ECG showed sinus rhythm 56/min with normal atrioventricular conduction and ST segment elevation of 3-4 mm in leads V1-V2, T wave inversion pattern in leads I, II, aVL, V3-V6 with loss of R- voltages in leads V2, V3 all suggestive of an anterior wall myocardial infarction. Total serum creatine kinase (CK) and CK-MB isoenzyme were normal, troponine I and T measurement were not available in our laboratory at that time. Patient received thrombolytic therapy (i.v. Streptokinase 1.5 x 106 U) over 60 minutes without succes. During and after thrombolytic therapy, ECG changes or increased values of cardiac enzymes were not detected. Next morning the patient was reffered for echocardiography. Transthoracic echocardiography showed normal left ventricular contractility and normal ejection fraction. Transesophageal echocardiography showed a large right atrial sessil mass (50 mm x 36 mm) arising from the interatrial septum. Coronary angiography confirmed moderate left ventricular enlargement with normal ejection fraction with normal coronary arteries. Patient underwent cardiac surgery. The tumor was adherent to the atrial wall in the region of the fosa ovalis, and completely removed. Histology confirmed that tumor was myxoma. The patient had an uncomplicated recovery.

[Echocardiographic assessment of diagnosis and prognosis of biopsy-proven amyloid cardiomyopathy]. / Ehokardiografska procjena dijagnoze i prognoze biopsijom dokazane amiloidne kardiomiopatije.

Amyloid cardiomyopathy is myocardial infiltrative disorder which mostly has been seen as the consequence of systemic amiloidosis. The diffuse global myocardial infiltration of nonfunctional amyloid displaces the contractile myocites giving rice to relaxation abnormality and diastolic dysfunction of restrictive or congestive type of both ventricles, but more frequently with right-sided congestion, while systolic left ventricular function deteriorates late in disease process. We report a patient with amyloid cardiomyopathy and nephrotic syndrome underlying primary amiloidosis. Our aim is to point out at echocardiographic assessment of diagnosis and prognosis of amyloid cardiomyopathy, which is proven by postmortal endomyocardial biopsy. The hallmark of echocardiographic diagnostics are the findings of the thickened ventricular and septal walls, small ventricular cavities, dilated atria with thickened interatrial septum and atrioventricular valves, and granular-sparkling and hyperrefractile myocardium. Doppler assessment diagnostically gives us the insight in restrictive physiology of both ventricles, and the inverse relation of the left ventricular thickness and voltage on the ECG is high specific. Echocardiographic evaluation of mean left ventricular thickness in amyloid cardiomyopathy is very important prognostic parameter. so that if it is > or =15 mm, median survival is 0.4 years, whereas in our patient with median thickness of 2.76 cm the survival was only three months. The advanced diastolic dysfunction of the left ventricle with an increased transmitral E/A ratio and deceleration time of < or =150 ms is strong predictor of cardiac death. In this case of restrictive transmitral flow E/A was 1.7 and DT 100 ms and they were ominous prognostic signs of survival.

[Significance of transesophageal echocardiography in the diagnosis of atrial tumor]. / Znacenje transezofagusne ehokardiografije u dijagnostici tumora atrija.

THE AIM OF WORK: To assess the diagnostic accuracy and clinical significance of transesophageal echocardiography (TEE) in the diagnosis of atrial tumors. The authors own experiences with use of TEE images in the assessment of atrial tumors are reported. PATIENTS AND METHODS: The study group consisted of 18 consecutive patients (9 women and 9 men), age range 40-72 years (mean age 60.5+/-10.1) years. Authors prospectively analyzed the results of 615 TEE in nine-years period (between May 1996 - March 2005). RESULTS: We detected 16 atrial myxomas in 15 patients, one fibroelastoma, one leiomyosarcoma, and one metastatic adenocarcinoma. The fibroelastoma, leiomyosarcoma, and metastatic carcinoma were found in right atrium. There was no false negative TEE diagnosis, was one false positive diagnosis, yielding a 95% sensitivity and specifity of TEE in detection atrial tumor. Seventeen patients referred for cardiac surgery, and TEE diagnosis was confirmed by pathohistology. Patient with right atrial metastatatic adenocarcinoma is not surgically treated. This patient treated with chemotherapy and radiotherapy because pulmonary adenocarcinoma. TTE detected atrial tumor in 15 (83%) patients. CONCLUSION: Results of this work suggested that TEE is a safe procedure, high sensitive and specific, and accurate in the diagnosis of atrial tumors. The ability of TEE to visualize both atria with great diagnostic accuracy makes it a very valuable procedure in the detection of atrial tumors.

Echocardiographic features of adult tetralogy of Fallot with natural palliative correction by patent ductus arteriosus.

A thirty-year-old man with the diagnosis of the tetralogy of Fallot and patent ductus arteriosus was admitted to our hospital because of a syncope. He reported no previous symptoms. We diagnosed adult tetralogy of Fallot, which included all four characteristic anomalies: ventricular septal defect, overriding aorta, pulmonary artery stenosis, and right ventricular hypertrophy. The associated persistent ductus arteriosus and the presence of compensatory arteriovenous communications produced a continuous flow load on the left ventricle, which resulted in moderate left ventricular hypertrophy, but without symptoms of pulmonary congestion or cardiac decompensation. Anatomic diagnosis and hemodynamic assessment were established by transthoracic and transesophageal echocardiography, with incidental finding of a quadricuspid aortic valve. To the best of our knowledge, our case of the adult form of Fallot's tetralogy associated with both patent ductus arteriosus and quadricuspid aortic valve is the first one ever described. It is well known that patients with tetralogy of Fallot who do not undergo operation in childhood have short survival, which depends predominantly on the degree of pulmonary artery stenosis and early development of collateral circulation to the lungs. Long-term persistence of natural aortopulmonary anastomosis with systemic collateral circulation to the lungs and remodeling of the heart, with better hemodynamic balance as well as the presence of mild pulmonary artery stenosis probably enhanced the survival of our patient.