Infective endocarditis in patients with bicuspid aortic valve: Clinical characteristics, complications, and prognosis. / Endocarditis infecciosa sobre válvula aórtica bicúspide: características clínicas, complicaciones y pronóstico.

INTRODUCTION: Bicuspid aortic valve (BAV) is the most frequent congenital cardiac disease. It is associated to a higher risk of cardiovascular complications, including infective endocarditis (IE). METHODS: Retrospective, observational and single centre study that included all patients with IE diagnosed between 1996 and 2014. An analysis was made of the epidemiological, clinical, microbiological and echocardiographic data, complications during hospital admission, need for surgery, in-hospital mortality, and 1-year follow-up. Cases with endocarditis on prosthetic valves or other locations were excluded, as well as those for which the aortic valve morphology had not been accurately defined. A comparative statistical analysis was performed between BAV and tricuspid (TAV). RESULTS: Of a total of 328 cases with IE, 118 (35.67%) were on aortic valve, with 18 (16.22%) of them being BAV. The BAV cases were younger than TAV (51±19.06 vs. 60.83±15.73 years, P=.021) and they had less comorbidity (Charlson 0.67±0.77 vs. 1.44±1.64, P=.03).). There was a higher tendency of Staphylococcal origin (38.9 vs. 21.5%, P=.137), and 55.6% showed peri-valvular complications (TAV 16.1%, P=.001), in particular, abscesses (38.9 vs.16.1%, P=.047). BAV was the only predictive factor of peri-valvular complications (OR 7.87, 95% CI; 2.38-26.64, P=.001). Patients with BAV had more surgery during their admission (83.3 vs. 44.1%, P=.004), had less in-hospital mortality, with no statistical significance (5.6 vs. 25.8%, P=.069), and 1-year survival was significantly superior (93.8 vs 69.3%, P=.048). CONCLUSIONS: Patients with IE on BAV are young, with low comorbidity. They frequently present with peri-valvular complications and they often require early surgery. Compared to TAV cases, in-hospital mortality is lower and 1-year survival is significantly higher.

Survival and predictive factors of mortality after 30 days in patients treated with percutaneous implantation of the CoreValve aortic prosthesis.

BACKGROUND: Few data exist on the clinical impact of transcatheter aortic valve implantation (TAVI) in patients with symptomatic aortic stenosis and a high surgical risk. The aim of this study was to determine the survival and the factors predicting mortality after 30 days post-TAVI with the CoreValve prosthesis (Medtronic, Minneapolis, MN). METHODS: From April 2008 to October 2010, the CoreValve prosthesis (Medtronic) was implanted in 133 consecutive high-risk surgical patients with symptomatic severe aortic stenosis. RESULTS: The mean age was 79.5 ± 6.7 years. The logistic European System for Cardiac Operative Risk Evaluation was 21.5% ± 14%. The implantation success rate was 97.7%. In-hospital mortality was 4.5%, and the combined end point of death, vascular complications, myocardial infarction, or stroke had a rate of 9%. Survival at 12 and 24 months was 84.5% and 79%, respectively, after a mean follow-up of 11.3 ± 8 months. The New York Heart Association functional class improved from 3.3 ± 0.5 to 1.18 ± 0.4 and remained stable at 1 year. A high Charlson index (hazard ratio [HR] 1.44, 95% CI 1.09-1.89, P < .01) and a worse Karnofsky score before the procedure (HR 0.95, 95% CI 0.92-0.99, P = .021) were predictors of mortality after 30 days. CONCLUSIONS: Transcatheter aortic valve implantation with the CoreValve prosthesis for patients with aortic stenosis and a high surgical risk is a safe, efficient option resulting in a medium-term clinical improvement. Survival during follow-up depends on the associated comorbidities. Early mortality beyond 30 days is predicted by preoperative comorbidity scores and the functional status of the patient.

Role of age and comorbidities in mortality of patients with infective endocarditis.

PURPOSE: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. METHODS: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. RESULTS: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32-3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39-1.88),and non-performed surgery (HR:1.64;95% CI:11.16-1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. CONCLUSION: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group.

Aortitis as a Rare Cause of Aortic Aneurysm and Valve Regurgitation: Is Repair Precluded?

Aortitis is an infrequent cause of aortic root dilatation and aortic valve regurgitation. Valve-sparing procedures have been proposed, but there is not clear evidence of which is the treatment of choice. We report the case of a 38-year-old pregnant lady with a diagnosis of idiopathic aortitis associated with aortic root aneurysm and severe aortic valve regurgitation.

[Effect of exercise on systolic left ventricular outflow velocity in healthy adults]. / Efecto del ejercicio sobre las velocidades de flujo sistólico ventricular izquierdo en adultos sanos.

The occurrence of exercise-induced dynamic obstruction of the left ventricular outflow tract in patients without cardiomyopathy has recently been reported. However, it is not known if this phenomenon is a normal response to exercise in healthy adults. We studied 23 healthy adults using exercise Doppler echocardiography. We measured the left ventricular outflow velocity at rest and after maximum tolerated exercise. After a mean exercise duration of 12 min 45 s (2 min 32 s), the heart rate was 97.61 (6.71)% of the theoretical maximum. Left ventricular outflow velocity increased from 1.07 (0.18) m/s (range: 0.77-1.44 m/s) to 1.58 (0.35) m/s (range: 1.09-2.4 m/s). In healthy adults, exercise increased the left ventricular outflow velocity by 50%, though in no subject was it greater than 2.5 m/s. This observation appears to rule out the possibility that a high intraventricular pressure gradient is a normal response to exercise in healthy adults.

[Effect of statin treatment begun early after acute myocardial infarction on endothelial function in patients with normal levels of cholesterol. VAATOPE Study (VAlue of ATOrvastatin in Postinfarction Endothelium)]. / Influencia del tratamiento temprano con estatinas en la función endotelial tras el infarto de miocardio en pacientes con valores normales de colesterol. Estudio VAATOPE (VAlue of ATOrvastatin in Postinfarction Endothelium).

BACKGROUND AND OBJECTIVE: Recent studies have suggested that statins reduce the rate of subsequent coronary events when these drugs are indicated early alter an acute coronary event. One potential mechanism by which these drugs might reduce the likelihood of such events is by enhancing endothelial function. The aim of this study was to determine whether early cholesterol reduction with atorvastatin improved endothelial function after acute myocardial infarction in patients with normal cholesterol levels. PATIENTS AND METHOD: Patients with a first acute myocardial infarction and normal levels of cholesterol were assigned to treatment with 10 mg atorvastatin (n = 15) or placebo (n = 15) for 8 weeks. Patients who had previously received treatment with statins were excluded. Brachial ultrasound was used to measure endothelium-dependent flow-mediated dilation and response to endothelium-independent nitroglycerin. Total and LDL cholesterol levels and the distribution of risk factors were similar on admission and before randomization in both groups. All patients were assessed between 5 and 7 days postinfarction and after 8 weeks. RESULTS: Total and LDL cholesterol levels were significantly decreased after atorvastatin treatment. Total cholesterol decreased by 11% (p < 0.01) and LDL cholesterol by 18% (p < 0.01). Without atorvastatin flow-mediated dilation was unchanged (mean [SEM] 9.3 [1.7%] to 10.6 [1.7%]) but it increased with atorvastatin (8.9 [1.4%] to 16.5 [1.7%], p < 0.05). The response to nitroglycerin was similar in both groups during the period of study. CONCLUSIONS: The early administration of atorvastatin appears to enhance endothelial function in patients with acute myocardial infarction and normal levels of cholesterol.

Incidence and prognosis implications of long term left ventricular reverse remodeling in patients with dilated cardiomyopathy.

BACKGROUND: Left ventricular reverse remodeling (LVRR) in dilated cardiomyopathy is poorly known within the context of current therapeutic approach. Our goal is to describe the present incidence of LVRR, the factors able to predict it and the long term prognosis of these patients. METHODS AND RESULTS: We performed a retrospective analysis of a cohort or 387 consecutive outpatients. Mean follow-up was 50.4 ± 28.4 months. Sustained LVRR occurred in 57.6% of patients. The number of coronary arteries with severe stenosis (HR 0.69, 95% CI 0.55-0.86; p=0.001), New York Heart Association Functional Class (NYHA FC) (HR 0.39, 95% CI 0.27-0.54; p<0.001) as well as the severity of mitral regurgitation (MR) at the end of follow-up (HR 0.42, 95% CI 0.30-0.58; p<0.001) and the time until first event (HR 1.02, 95% CI 1.01-1.03; p<0.001) were independent predictors of left ventricular ejection fraction improvement. LVRR was tightly related to prognosis due to the fact that both improvement in cardiac function achieving normal or slightly impaired LVEF (HR 0.31, 95% CI 0.17-0.56; p<0.001) and shorter time to achieve LVRR (HR 0.99, 95% CI 0.98-0.99; p=0.017) formed part of the best model for predicting events in DCM. CONCLUSION: More than half of the patients showed sustained LVRR associated with a significantly better prognosis. Fewer numbers of coronary arteries with severe stenosis, milder NYHA FC and the absence of significant MR at the end of follow-up as well as longer event free period formed a simple model to prognosticate LVRR. LVRR and the time to achieve it were strongly related to long term prognosis in patients with DCM.

Infective endocarditis in hypertrophic cardiomyopathy: A multicenter, prospective, cohort study.

Infective endocarditis (IE) complicating hypertrophic cardiomyopathy (HCM) is a poorly known entity. Although current guidelines do not recommend IE antibiotic prophylaxis (IEAP) in HCM, controversy remains.This study sought to describe the clinical course of a large series of IE HCM and to compare IE in HCM patients with IE patients with and without an indication for IEAP.Data from the GAMES IE registry involving 27 Spanish hospitals were analyzed. From January 2008 to December 2013, 2000 consecutive IE patients were prospectively included in the registry. Eleven IE HCM additional cases from before 2008 were also studied. Clinical, microbiological, and echocardiographic characteristics were analyzed in IE HCM patients (n = 34) and in IE HCM reported in literature (n = 84). Patients with nondevice IE (n = 1807) were classified into 3 groups: group 1, HCM with native-valve IE (n = 26); group 2, patients with IEAP indication (n = 696); group 3, patients with no IEAP indication (n = 1085). IE episode and 1-year follow-up data were gathered.One-year mortality in IE HCM was 42% in our study and 22% in the literature. IE was more frequent, although not exclusive, in obstructive HCM (59% and 74%, respectively). Group 1 exhibited more IE predisposing factors than groups 2 and 3 (62% vs 40% vs 50%, P < 0.01), and more previous dental procedures (23% vs 6% vs 8%, P < 0.01). Furthermore, Group 1 experienced a higher incidence of Streptococcus infections than Group 2 (39% vs 22%, P < 0.01) and similar to Group 3 (39% vs 30%, P = 0.34). Overall mortality was similar among groups (42% vs 36% vs 35%, P = 0.64).IE occurs in HCM patients with and without obstruction. Mortality of IE HCM is high but similar to patients with and without IEAP indication. Predisposing factors, previous dental procedures, and streptococcal infection are higher in IE HCM, suggesting that HCM patients could benefit from IEAP.

[Collagen synthesis and heart failure]. / Síntesis de colágeno e insuficiencia cardíaca.

Little is known about collagen metabolism in heart failure, with or without left ventricular systolic dysfunction. We studied serum concentrations of the carboxy-terminal propeptide of procollagen type I (PIP), a marker of collagen type-I synthesis, and of the carboxy-terminal telopeptide of collagen type I (ICTP), a marker of collagen type-I degradation, in 70 patients admitted for heart failure (35 with depressed left ventricular systolic function and 35 with preserved left ventricular systolic function) and in 30 control subjects. Patients with kidney failure, liver disease, metabolic bone disease, rheumatic disease, recent (within 3 months) major trauma or surgery, or serious wounds were excluded. The concentration of the collagen synthesis marker, PIP, was higher in heart failure patients than control subjects, at 140+/-56.38 mg/L vs 113.66+/-36.6 microg/L, respectively (P=.01). However, there was no difference in the concentration of the collagen degradation marker, ICTP, between heart failure patients and control subjects, at 2.89+/-2.37 mg/L vs 2.26+/-1.7 microg/l, respectively. In heart failure patients, left ventricular systolic function had nonsignificant effect on the PIP or ICTP concentration.

[Systolic ventricular dysfunction, a new marker of coronary artery disease in patients with aortic stenosis without previous myocardial infarction]. / Disfunción ventricular sistólica, un nuevo marcador de enfermedad coronaria en pacientes con estenosis aórtica sin infarto de miocardio previo.

Identification of clinical factors associated with coronary artery disease could obviate the need for coronary angiography in selected patients with severe aortic stenosis. We studied 315 patients (68 [8] years) with severe aortic stenosis without previous infarction who underwent coronary angiography. In the univariate analysis, age (P = .001), dyslipidemia (P = .003), angina (P = .018), aortic gradient (P = .001) and reduced ejection fraction (P = .006) were predictors of coronary artery disease. After multivariate analysis, age (OR = 1.079, P = .01), ejection fraction < 40% (OR = 2.685, P = .02), angina (OR = 2.518, P = .04) and dyslipidemia (OR = 2.34, P = .008) were the factors independently associated with coronary artery disease. Left ventricular dysfunction correlated independently with the presence of coronary artery disease.

[Dynamic left ventricular outflow tract obstruction induced by exercise]. / Obstrucción dinámica intraventricular izquierda inducida por esfuerzo.

INTRODUCTION AND OBJECTIVES: Dynamic left intraventricular outflow tract obstruction occurs occasionally in patients without hypertrophic cardiomyopathy. We hypothesized that dynamic intraventricular obstruction might occur during effort in patients with angina or dyspnea without evident disease. The objective of this prospective study was to investigate: a) whether it appears with effort; b) its incidence, magnitude and determining factors, and c) its clinical course. PATIENTS AND METHOD: We performed baseline and stress Doppler echocardiography in 211 patients with angina, dyspnea or both with exercise. Patients with previous myocardial infarction, valvular heart disease, ventricular dysfunction or ventricular hypertrophy without hypertension were excluded. Dynamic intraventricular obstruction was defined as intracavitary flow velocity > or =2.5 m/s. RESULTS: 134 patients (59 women) were included: mean age was 58 (9) years; history of hypertension was present in 69.7%, dyslipidemia in 35.8% and diabetes in 24.6%. Dynamic intraventricular obstruction appeared in 18 patients (13.4%), with gradients ranging between 25 and 53 mmHg (mean 32.19 [6.6]). Demographic variables, cardiovascular risk factors and exercise performed were similar in group A (with obstruction) and group B (without obstruction). No patient in group A had evidence of ischemia. Five patients in this group had symptoms during exercise; the gradients were greater in these patients (42.65 [10.5] vs 28.15 [2.37] mmHg; P<.0001) than in the remaining group A patients. Left ventricular outflow tract size was found to be the only independent predictive factor in the multivariate analysis. After 369.9 (133.5) days of follow-up, no cardiac events were recorded. CONCLUSIONS: Our study suggests that some patients with angina or dyspnea without evidence of ischemia may develop dynamic left ventricular outflow tract obstruction induced by effort.

Influence of a multidisciplinary alert strategy on mortality due to left-sided infective endocarditis.

INTRODUCTION AND OBJECTIVES: Mortality from left-sided infective endocarditis remains very high. The aim of this study was to assess the impact of a multidisciplinary alert strategy (AMULTEI), based on clinical, echocardiographic and microbiological findings, implemented in 2008 in a tertiary hospital. METHODS: Cohort study comparing our historical data series (1996-2007) with the number of patients diagnosed with left-sided endocarditis from 2008-2011 (AMULTEI). RESULTS: The AMULTEI cohort included 72 patients who were compared with 155 patients in the historical cohort. AMULTEI patients were significantly older (62.5 vs 57.9 years in the historical cohort; P=.047) and had higher comorbidity (Charlson index, 3.33 vs 2.58 in the historical cohort; P=.023). There was also a trend toward more enterococcal etiology in the AMULTEI group (20.8% vs 11.6% in the historical cohort; P=.067). In the AMULTEI group, early surgery was more frequently performed (48.6% vs 23.2%; P<.001) during hospitalization, the incidence of septic shock was significantly lower (9.7% vs 24.5%; P=.009) and there was a trend toward reductions in neurological complications (19.4% vs 29.0%; P=.25) and severe heart failure (12.5% vs 18.7%; P=.24). In-hospital mortality and mortality during the first month of follow-up were significantly lower in the AMULTEI group (16.7% vs 36.1%; P=.003). CONCLUSIONS: Despite the trend toward older age and more comorbidity measured by the Charlson index, early mortality was significantly lower in patients treated with the AMULTEI strategy.

Initial experience of percutaneous treatment of mitral regurgitation with MitraClip® therapy in Spain.

INTRODUCTION AND OBJECTIVES: Symptomatic mitral regurgitation has an unfavorable prognosis unless treated by surgery. However, the European registry of valvular heart disease reports that 49% of patients with this condition do not undergo surgery. Percutaneous treatment of mitral regurgitation with MitraClip® has been proved a safe, efficient adjunct to medical treatment in patients with this profile. The objective of the present study is to describe initial experience of MitraClip® therapy in Spain. METHODS: Retrospective observational study including all patients treated between November 2011 and July 2013 at the 4 Spanish hospitals recording the highest numbers of implantations. RESULTS: A total of 62 patients (77.4% men) were treated, mainly for restrictive functional mitral regurgitation (85.4%) of grade III (37%) or grade IV (63%), mean (standard deviation) ejection fraction 36% (14%), and New York Heart Association functional class III (37%) or IV (63%). Device implantation was successful in 98% of the patients. At 1 year, 81.2% had mitral regurgitation ≤ 2 and 90.9% were in New York Heart Association functional class ≤ II. One periprocedural death occurred (sepsis at 20 days post-implantation) and another 3 patients died during follow-up (mean, 9.1 months). Two patients needed a second implantation due to partial dehiscence of the first device and 2 others underwent heart transplantation. CONCLUSIONS: In Spain, MitraClip® therapy has principally been aimed at patients with functional mitral regurgitation, significant systolic ventricular dysfunction, and high surgical risk. It is considered a safe alternative treatment, which can reduce mitral regurgitation and improve functional capacity.

Hereditary patterns of bicuspid aortic valve in a hundred families.

BACKGROUND: To study the following characteristics of bicuspid aortic valves (BAVs): 1) the recurrence rate in our population, 2) patterns of hereditary transmission in different BAV morphologies and 3) the aortic dimensions of BAVs in first-degree relatives (FDRs). METHODS: A cross-sectional, prospective study of 100 consecutive families of BAV patients attending a university hospital. The following aortic valve morphologies were analysed and categorised: fusion of the right and left coronary cusps (BAV type A), right and noncoronary cusps (type B) and of the left and noncoronary cusps (type C). RESULTS: There were 553 subjects studied, 100 cases with a BAV (46.8±15 years, 66% male, type 67% A, 32% B and 1% C; 42% with aortic dilatation), 348 FDRs (44.8% male), and 105 healthy control subjects (50% male). We detected 16 BAVs among 348 FDRs. The recurrence rates were 15% for families, 4.6% for FDRs, 7.05% in men and 2.60% in women. The morphologic concordance in family members was 68.8%. The aortic dimensions in 270 adult FDRs with a tricuspid aortic valve were significantly smaller compared with BAV patients (sinus index diameter 1.60±0.19 cm/m(2) vs. 1.82±0.29 cm/m(2), p<0.001; tubular index diameter 1.51±0.23 cm/m(2) vs. 2.00±0.45 cm/m(2), p<0.001) and similar to 103 control subjects(sinus index diameter 1.60±0.19 cm/m(2) vs. 1.59±0.17 cm/m(2), p=0.600 and tubular index diameter 1.51±0.23 cm/m(2) vs. 1.53±0.18 cm/m(2), p=0.519). CONCLUSIONS: In our population, the BAV recurrence rate in FDRs was low (4.6%). The hereditary transmission of morphologic BAV types seems by chance, and the aortic dimensions in tricuspid FDRs are normal.

Percutaneous treatment of a dysfunctional aortic bioprosthesis with the CoreValve(®) prosthesis.

Recently, percutaneous aortic valve replacement has emerged as a therapeutic option for patients with severe symptomatic aortic stenosis and a high surgical risk. We report our initial experience in four patients with percutaneous implantation of a CoreValve aortic prosthesis to treat aortic bioprosthesis dysfunction involving aortic stenosis or regurgitation. In-hospital and medium-term outcomes were analyzed. The procedure was performed under local anesthesia and guided by angiography. The prosthesis was implanted successfully in all patients, although a second prosthesis was required in one case because the first was positioned too high. There were no major complications. After a mean follow-up of 7 months (SD, 4.7), all patients remained asymptomatic.

Left ventricular deformation and two-dimensional echocardiography: temporal and other parameter values in normal subjects.

Segmental contractility can be assessed quantitatively by analyzing deformation, or strain, and the rate of deformation, or the strain rate. This type of analysis can be performed using either tissue Doppler imaging or, more recently, two-dimensional speckle-tracking echocardiography. The aim of this study was to determine typical parameter values in healthy subjects and their reproducibility. The study involved 105 healthy individuals, including 55 women (52.45%). Their mean age was 38.8 ± 9.5 years (range, 20-59 years). All underwent speckle-tracking echocardiography with velocity vector imaging. Mean values for the strain and strain rate for each segment as well as for the time-to-peak normalized by the length of the cycle (TPN) were obtained. The resulting mean values were: circumferential strain, 22.2 ± 4.81% with a TPN of 0.39 ± 0.06; longitudinal strain, 19.84 ± 4.59% with a TPN of 0.42 ± 0.06; circumferential strain rate, 1.64 ± 0.48 1/s with a TPN of 0.23 ± 0.06; and longitudinal strain rate, 1.3 ± 0.49 1/s with a TPN of 0.21 ± 0.09. Intra- and inter-observer variability were moderate in magnitude.