Predictors of aortic pulse wave velocity in the elderly with severe aortic stenosis.

UNLABELLED: Predictors of aortic pulse wave velocity (AoPWV) were not previously studied in the elderly with severe aortic stenosis (AS). We aimed to compare the AoPWV in these patients with matched controls and to study the predictors of AoPWV in this population. We measured the AoPWV during cardiac catheterisation in 40 patients with severe AS and 20 matched controls. AoPWV in both groups was similar (p = 0.198) and lied within normal reference value for age in 68 % of elderly with severe AS. Central systolic blood pressure (SBP) (adjusted ß = 0.45, p = 0.001) and glomerular filtration rate (GFR) (adjusted ß = -0.29, p = 0.023) were the only independent predictors of AoPWV in AS group. Central SBP >140 mmHg was the best predictor of abnormal AoPWV (≥14.6 m/s) with 100 % sensitivity and 70 % specificity, p < 0.001. CONCLUSION: AoPWV is not increased in the elderly with severe AS compared to controls, and lies within the reference value for age in the majority of these patients. Central SBP >140 mmHg best predicts abnormal AoPWV in the elderly with severe AS.

Value of certain echocardiographic findings in the initial suspicion of Behçet's disease.

PURPOSE: To describe the echocardiographic findings detected as first manifestations of Behçet's disease (BD) and compare these findings with those detected in established cases of BD receiving regular medical treatment. METHODS: Two groups of patients were studied. Group 1 comprised 41 patients with BD on regular medical treatment. Group 2 comprised 5 previously healthy patients who presented to the cardiology department because of cardiac symptoms and were diagnosed in retrospect during hospitalization as BD. Thirty-two age- and sex-matched individuals served as control subjects (control group). All patients and controls underwent complete M-mode, two-dimensional, and Doppler transthoracic echocardiographic examinations. RESULTS: Of the 41 treated patients with BD (mean age: 32 ± 8 years, 90% males, mean duration since diagnosis: 14.5 years), only 1 patient was found to have severe aortic regurgitation secondary to aortic root dilation. On the other hand, the 5 previously healthy patients who presented with cardiac symptoms (mean age: 24 ± 6 years, all males) had significant cardiac involvement and evident echocardiographic findings (P < 0.001). Four cases had intracardiac masses: 3 in the right atrium (RA), 1 in the right ventricle (RV), while the last patient had pericardial effusion (PE). All these patients were diagnosed in retrospect as BD. The RA masses disappeared on medical therapy, while the RV mass was surgically excised and proved to be multiple thrombi histopathologically. The patient with PE had recurrent attacks of massive effusion so a pericardial window was performed surgically. CONCLUSION: Diagnosis of BD might be initially suspected by the cardiologists based on certain echocardiographic findings, namely the presence of right-sided masses. Diagnosis of BD in such patients has important therapeutic implications and accordingly prognostic value.

Ventricular function in patients with end-stage renal disease starting dialysis therapy: a tissue Doppler imaging study.

BACKGROUND: Heart failure is prevalent in end-stage renal disease (ESRD) patients on long-term dialysis. Detection of right ventricular (RV) dysfunction before starting dialysis may help to identify patients at a higher risk of developing heart failure. AIM: To assess RV function in predialysis patients using tissue Doppler imaging (TDI) derived myocardial performance index of RV (MPI-RV). METHODS: Echocardiography including pulsed TDI of lateral tricuspid annulus was performed in 41 patients with ESRD before starting dialysis therapy and 12 age and gender matched healthy controls. RV dysfunction was defined as MPI > 0.4; a value above the median MPI in controls. RESULTS: Compared to controls, ESRD patients had significantly higher blood pressure and lower hemoglobin level. MPI-RV was significantly impaired in ESRD patients compared to control (0.6 vs. 0.4, P < 0.001). RV dysfunction was identified in 23 ESRD patients (56%). ESRD patients had significantly lower e' velocity and e'/a' ratio as compared with controls. Pulmonary hypertension was detected in 15 (36.5%) patients. Among ESRD patients, no correlation was detected between MPI-RV and calculated mean pulmonary artery pressure (r = -0.13, P = 0.47), pulmonary artery systolic pressure (r =-0.12, P = 0.6), left ventricular ejection fraction (r = 0.294, P = 0.06), or MPI of left ventricle (r = 0.3, P = 0.065). ESRD patients with and without pulmonary hypertension had similar MPI-RV (0.6 vs.0.62, P = 0.32). CONCLUSION: Subclinical RV dysfunction-as estimated by TDI derived MPI-is highly prevalent among ESRD patients even before starting dialysis therapy. Pulmonary hypertension is not significantly associated with RV dysfunction in these patients.

Intracolonic Administration of Vancomycin in Intensive Care Unit Patients with Severe Clostridium Difficile Colitis.

BACKGROUND: Clostridium difficile infection (CDI) is a major cause of antibiotic-associated diarrhea worldwide. The incidence of sepsis has been shown to be increasing due to severe or fulminant colitis. Oral vancomycin is the treatment of choice for CDI, but it is often ineffective in patients in the intensive care unit (ICU) due to poor intestinal motility. We present a review of eight cases with severe to fulminant CDI treated with adjunctive intracolonic vancomycin (ICV) administration. METHODS: A retrospective chart review identified patients in sepsis with severe colitis and positive Clostridium difficile toxin A or B. Patients who had failed standard therapy for CDI were given adjunctive ICV through an enteric tube, which was inserted via colonoscopy. To indicate the severity of patients, the patients selected had required vasopressor support. RESULTS: Eight patients (37.5% females) received this adjunctive treatment; the mean age was 73.25. The average Acute Physiology and Chronic Health Evaluation (APACHE) 2 score at the time of the procedure was 39. The median length of stay was 5.5 days, with in-hospital mortality of 37.5% and an average time to death of 1.33 days from the day of colonoscopy.  Conclusion: Colonoscopic decompression and administration of vancomycin for fulminant CDI using an enteric tube can have favorable outcomes in severely ill patients whose surgical options carry a high risk of mortality. Further larger randomized controlled trials are needed to evaluate its efficacy.

Clinical features and outcomes of infective endocarditis in Egypt: an 11-year experience at a tertiary care facility.

BACKGROUND: Few data are available on the characteristics of infective endocarditis (IE) cases in Egypt. The aim of this work is to describe the characteristics and outcomes of IE patients and evaluate the temporal changes in IE diagnostic and therapeutic aspects over 11 years. RESULTS: The IE registry included 398 patients referred to the Endocarditis Unit of a tertiary care facility with the diagnosis of possible or definite IE. Patients were recruited over two periods; period 1 (n = 237, 59.5%) from February 2005 to December 2011 and period 2 (n = 161, 40.5%) from January 2012 to September 2016. An electronic database was constructed to include information on patients' clinical and microbiological characteristics as well as complications and mortality. The median age was 30 years and rheumatic valvular heart disease was the commonest underlying cardiac disease (34.7%). Healthcare-associated IE affected 185 patients (46.5%) and 275 patients (69.1%) had negative blood cultures. The most common complications were heart failure (n = 148, 37.2%), peripheral embolization (n = 133, 33.4%), and severe sepsis (n = 100, 25.1%). In-hospital mortality occurred in 108 patients (27.1%). Period 2 was characterized by a higher prevalence of injection drug use-associated IE (15.5% vs. 7.2%, p = 0.008), a higher staphylococcal IE (50.0% vs. 35.7%, p = 0.038), lower complications (31.1% vs. 45.1%, p = 0.005), and a lower in-hospital mortality (19.9% vs. 32.1%, p = 0.007). CONCLUSION: This Egyptian registry showed high rates of culture-negative IE, complications, and in-hospital mortality in a largely young population of patients. Improvements were noted in the rates of complications and mortality in the second half of the reporting period.

Early severe coronary artery disease and aortic coarctation in a child with familial hypercholesterolaemia.

An 11-year-old boy presented with easy fatigability, multiple xanthomas, and absent pedal pulsations. Laboratory workup showed severe hypercholesterolaemia and non-invasive imaging revealed 'normally functioning' bicuspid aortic valve and tight aortic coarctation. Coronary angiography showed severe right coronary artery (RCA) stenosis. Medical treatment resulted in significant improvement of dyslipidaemia. We successfully performed balloon dilation and stenting of his coarctation, as well as percutaneous coronary intervention for RCA lesion.

Global cardiac risk assessment in the Registry Of Pregnancy And Cardiac disease: results of a registry from the European Society of Cardiology.

AIMS: To validate the modified World Health Organization (mWHO) risk classification in advanced and emerging countries, and to identify additional risk factors for cardiac events during pregnancy. METHODS AND RESULTS: The ongoing prospective worldwide Registry Of Pregnancy And Cardiac disease (ROPAC) included 2742 pregnant women (mean age ± standard deviation, 29.2 ± 5.5 years) with established cardiac disease: 1827 from advanced countries and 915 from emerging countries. In patients from advanced countries, congenital heart disease was the most prevalent diagnosis (70%) while in emerging countries valvular heart disease was more common (55%). A cardiac event occurred in 566 patients (20.6%) during pregnancy: 234 (12.8%) in advanced countries and 332 (36.3%) in emerging countries. The mWHO classification had a moderate performance to discriminate between women with and without cardiac events (c-statistic 0.711 and 95% confidence interval (CI) 0.686-0.735). However, its performance in advanced countries (0.726) was better than in emerging countries (0.633). The best performance was found in patients with acquired heart disease from developed countries (0.712). Pre-pregnancy signs of heart failure and, in advanced countries, atrial fibrillation and no previous cardiac intervention added prognostic value to the mWHO classification, with a c-statistic of 0.751 (95% CI 0.715-0.786) in advanced countries and of 0.724 (95% CI 0.691-0.758) in emerging countries. CONCLUSION: The mWHO risk classification is a useful tool for predicting cardiac events during pregnancy in women with established cardiac disease in advanced countries, but seems less effective in emerging countries. Data on pre-pregnancy cardiac condition including signs of heart failure and atrial fibrillation, may help to improve preconception counselling in advanced and emerging countries.

Intentional esophageal intubation to improve visualization during emergent endotracheal intubation in the context of massive vomiting: a case report.

Impaired visualization during intubation due to vomitus of gastric contents is a potential cause of failed intubation. An 82-year-old woman was intubated emergently for respiratory distress secondary to aspiration of gastric contents. Her intubation was hindered by the presence of a massive amount of ongoing vomitus that impaired visualization and overwhelmed all suction capabilities. Intentional blind intubation of the esophagus with an endotracheal tube was performed with successful diversion of ongoing vomitus away from the airway. Thereafter, after brief suctioning, the larynx was quickly visualized and the patient was successfully intubated.

Acute myocardial ischemia in adults secondary to missed Kawasaki disease in childhood.

Coronary artery aneurysms that occur in 25% of untreated Kawasaki disease (KD) patients may remain clinically silent for decades and then thrombose resulting in myocardial infarction. Although KD is now the most common cause of acquired heart disease in children in Asia, the United States, and Western Europe, the incidence of KD in Egypt is unknown. We tested the hypothesis that young adults in Egypt presenting with acute myocardial ischemia may have coronary artery lesions because of KD in childhood. We reviewed a total of 580 angiograms of patients ≤40 years presenting with symptoms of myocardial ischemia. Coronary artery aneurysms were noted in 46 patients (7.9%), of whom 9 presented with myocardial infarction. The likelihood of antecedent KD as the cause of the aneurysms was classified as definite (n = 10), probable (n = 29), or equivocal (n = 7). Compared with the definite and probable groups, the equivocal group had more traditional cardiovascular risk factors, smaller sized aneurysms, and fewer coronary arteries affected. In conclusion, in a major metropolitan center in Egypt, 6.7% of adults aged ≤40 years who underwent angiography for evaluation of possible myocardial ischemia had lesions consistent with antecedent KD. Because of the unique therapeutic challenges associated with these lesions, adult cardiologists should be aware that coronary artery aneurysms in young adults may be because of missed KD in childhood.

Atrial Fibrillation or Flutter During Pregnancy in Patients With Structural Heart Disease: Data From the ROPAC (Registry on Pregnancy and Cardiac Disease).

OBJECTIVES: Atrial fibrillation (AF)/atrial flutter (AFL) during pregnancy in these women is associated with adverse outcome of pregnancy. BACKGROUND: The incidence, timing, and consequences of AF or AFL during pregnancy in patients with heart disease are not well known. METHODS: Between January 2008 to June 2011, 60 hospitals in 28 countries prospectively enrolled 1,321 pregnant women with congenital heart disease, valvular heart disease, ischemic heart disease, or cardiomyopathy in the ROPAC (Registry of Pregnancy and Cardiac Disease). We studied the incidence, onset, and predictors of AF/AFL during pregnancy and assessed the pregnancy outcome. An overview of the existing literature is provided. RESULTS: Seventeen women (1.3%) developed AF/AFL during pregnancy, mainly in the second trimester (61.5%). Univariable analysis identified the following pre-pregnancy risk factors for AF/AFL in pregnancy: AF/AFL before pregnancy (odds ratio [OR]: 7.1, 95% confidence interval [CI]: 1.5 to 32.8); mitral valvular heart disease (OR: 6.9, 95% CI: 2.6 to 18.3); beta-blocker use (OR: 3.3, 95% CI: 1.2 to 9.0); and left-sided lesions (OR: 2.9, 95% CI: 1.0 to 8.3). Maternal mortality was higher in women with than in women without AF/AFL (11.8% vs. 0.9%; p = 0.01), although heart failure was not seen more often. Low birth weight (<2,500 g) occurred more often in women with than in women without AF/AFL (35% vs. 14%; p = 0.02). CONCLUSIONS: AF/AFL occurs in 1.3% of pregnant patients with structural heart disease with a peak at the end of the second trimester. AF/AFL during pregnancy in cardiac patients is associated with unfavorable maternal outcome and also has an impact on fetal birth weight.

The use of cardioselective beta-blockers in a patient with idiopathic hypertrophic subaortic stenosis and chronic obstructive pulmonary disease.

The beta-adrenergic receptor blocking drugs are commonly used in the treatment of patients with idiopathic hypertropic subaortic stenosis (IHSS). These drugs, however, are contraindicated in patients with chronic obstructive pulmonary disease (COPD). We report the anesthetic management of a patient with IHSS complicated by severe COPD. We concluded that the beta(1) selective, ultra-short acting beta-blocker, esmolol, can be used intraoperatively when both conditions are present. The pathophysiology and the commonly used anesthetic drugs and practices for treatment of patients with IHSS are reviewed.

Effect of pretreatment antistreptokinase antibody and streptococcal infection on the efficacy and dosage of streptokinase in acute myocardial infarction.

OBJECTIVES: The objective of the study is to determine if the presence of antistreptokinase (ASK) antibody in the blood, leads to ineffective thrombolytic therapy with streptokinase (SK) in acute myocardial infarction (AMI) and to investigate if increased dose of streptokinase (2.5 million units) could improve the infarct-related artery (IRA) patency or the clinical outcome in these patients. METHODS: The study was conducted between 1994 and 2001 in 2 institutions; King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia and in Kasr El-Aini Faculty of Medicine, Cairo, Egypt. Fifty consecutive patients with acute myocardial infarction (AMI) were included in this prospective double blind, randomized study. All patients were given the allocated streptokinase dose (1.5 or 2.5 million units) and underwent angiography within 24 hours to establish the anatomy of coronary arteries and the patency of infarct-related artery. Antistreptokinase antibody assay was carried out in a core laboratory. RESULTS: The study results showed that the presence of ASK antibody or the administration of an increased dose of SK had no effect on improving the patency rate of the infarct-related artery. CONCLUSION: The presence of a previous streptococcal infection may not necessarily reduce the effect of SK on the patency of the IRA and/or clinical outcome in patients presenting with AMI. The administration of a larger than currently recommended dose of SK (2.5 million units) did not alter the clinical outcome because it did not improve the patency rate of the IRA. However, a larger study is needed to confirm these observations.