Retrospective analysis of endocarditis patients to investigate the eligibility for oral antibiotic treatment in routine daily practice.

BACKGROUND: According to the current guidelines of the European Society of Cardiology, patients with left-sided infective endocarditis are treated with intravenous antibiotics for 4-6 weeks, leading to extensive hospital stay and high costs. Recently, the Partial Oral Treatment of Endocarditis (POET) trial suggested that partial oral treatment is effective and safe in selected patients. Here, we investigated if such patients are seen in our daily clinical practice. METHODS: We enrolled 119 adult patients diagnosed with left-sided infective endocarditis in a retrospective, observational study. We identified those that would be eligible for switching to partial oral antibiotic treatment as defined in the POET trial (e.g. stable clinical condition without signs of infection). Secondary objectives were to provide insight into the time until each patient was eligible for partial oral treatment, and to determine parameters of longer hospital stay and/or need for extended intravenous antibiotic treatment. RESULTS: Applying the POET selection criteria, the condition of 38 patients (32%) was stable enough to switch them to partial oral treatment, of which 18 (47.3%), 8 (21.1%), 9 (23.7%) and 3 patients (7.9%) were eligible for switching after 10, 14, 21 days or 28 days of intravenous treatment, respectively. CONCLUSION: One-third of patients who presented with left-sided endocarditis in routine clinical practice were possible candidates for switching to partial oral treatment. This could have major implications for both the patient's quality of life and healthcare costs. These results offer an interesting perspective for implementation of such a strategy, which should be accompanied by a prospective cost-effectiveness analysis.

Global longitudinal strain to predict left ventricular dysfunction in asymptomatic patients with severe mitral valve regurgitation: literature review.

The optimal treatment strategy for asymptomatic patients with severe mitral valve regurgitation (MR) and preserved left ventricular (LV) function is challenging. This manuscript reviews the available literature on the value of left ventricular global longitudinal strain (LV-GLS) in predicting LV dysfunction after mitral valve surgery in these patients and discusses its current place in the treatment strategy. Studies were identified from Cochrane Library, SCOPUS, PubMed and Web of Science up to February 2018. The domain used was MR. The determinant was LV-GLS; other methods of deformation imaging were excluded. The examined outcome was LV dysfunction after surgery. A total of 144 articles were retrieved, of which 11 publications met the inclusion criteria, including a total of 2415 patients. Ten studies showed a significant correlation between preoperative LV-GLS and LV dysfunction postoperatively; one study reported a negative correlation. These studies suggest that LV-GLS is a predictor of LV dysfunction after surgery in asymptomatic patients with chronic MR. Hence, incorporation of LV-GLS for clinical decision-making in these patients might be of additional value. Further research is needed to confirm the role of LV-GLS in postoperative patients, and additionally in asymptomatic MR patients during a 'watchful waiting' strategy.

Invasive coronary physiology: a Dutch tradition.

Invasive coronary physiology has been applied since the early days of percutaneous transluminal coronary angioplasty, and has become a rapidly emerging field of research. Many physiology indices have been developed, tested in clinical studies, and are now applied in daily clinical practice. Recent clinical practice guidelines further support the use of advanced invasive physiology methods to optimise the diagnosis and treatment of patients with acute and chronic coronary syndromes. This article provides a succinct review of the history of invasive coronary physiology, the basic concepts of currently available physiological parameters, and will particularly highlight the Dutch contribution to this field of invasive coronary physiology.

Randomised comparison of a balloon-expandable and self-expandable valve with quantitative assessment of aortic regurgitation using magnetic resonance imaging.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is a safe and effective treatment for inoperable, intermediate- or high-risk patients with severe symptomatic aortic stenosis and has been associated with excellent clinical outcomes. A clinically relevant remaining problem is aortic regurgitation (AR) post-TAVI, which is associated with increased mortality. Therefore, we conducted a prospective randomised trial to assess the safety and efficacy of a first-generation self-expandable valve (SEV; CoreValve) and a third-generation balloon-expandable valve (BEV; Sapien 3) with respect to clinical outcomes and AR as determined quantitatively by magnetic resonance imaging (MRI). METHODS: The ELECT study was an investigator-initiated, single-centre trial involving patients with severe symptomatic aortic stenosis and with a clinical indication for transfemoral TAVI. Fifty-six patients were randomly assigned to the BEV or SEV group. RESULTS: AR determined quantitatively by MRI was lower in the BEV than in the SEV group [regurgitant fraction: 1.1% (0-8.0) vs 8.7% (3.0-14.8) for SEV; p = 0.01]. Secondary endpoints according to the criteria of the Second Valve Academic Research Consortium (VARC-2) showed BEV to have better early safety [0 (0%) vs 8 (30%); p = 0.002] at 30 days and a lower risk of stroke [0 (0%) vs 5 (21%); p = 0.01], major adverse cardiac and cerebrovascular events [0 (0%) vs 10 (38%); p < 0.001] or death [0 (0%) vs 5 (19%); p = 0.02] in the 1st year compared with SEV. CONCLUSIONS: The use of the latest generation of BEV was associated with less AR as quantitatively assessed by MRI. Although the use of MRI to quantify AR is not feasible in daily clinical practice, it should be considered as a surrogate endpoint for clinical outcomes in comparative studies of valves for TAVI. ClinicalTrials.gov number NCT01982032.

Feasibility and potential benefit of pre-procedural CMR imaging in patients with ischaemic cardiomyopathy undergoing cardiac resynchronisation therapy.

AIM: To determine the feasibility and potential benefit of a full cardiac magnetic resonance (CMR) work-up for assessing the location of scarred myocardium and the region of latest contraction (LCR) in patients with ischaemic cardiomyopathy (ICM) undergoing cardiac resynchronisation therapy (CRT). METHODS: In 30 patients, scar identification and contraction timing analysis was retrospectively performed on CMR images. Fluoroscopic left ventricular (LV) lead positions were scored with respect to scar location, and when placed outside scar, with respect to the LCR. The association between the lead position with respect to scar, the LCR and echocardiographic LV end-systolic volume (LVESV) reduction was subsequently evaluated. RESULTS: The CMR work-up was feasible in all but one patient, in whom image quality was poor. Scar and contraction timing data were succesfully displayed on 36-segment cardiac bullseye plots. Patients with leads placed outside scar had larger LVESV reduction (-21 ± 21%, n = 19) compared to patients with leads within scar (1 ± 25%, n = 11), yet total scar burden was higher in the latter group. There was a trend towards larger LVESV reduction in patients with leads in the scar-free LCR, compared to leads situated in scar-free segments but not in the LCR (-34 ± 14% vs -15 ± 21%, p = 0.06). CONCLUSIONS: The degree of reverse remodelling was larger in patients with leads situated in a scar-free LCR. In patients with leads situated within scar there was a neutral effect on reverse remodelling, which can be caused both by higher scar burden or lead position. These findings demonstrate the feasibility of a CMR work-up and potential benefit in ICM patients undergoing CRT.

Infective endocarditis in the Netherlands: current epidemiological profile and mortality : An analysis based on partial ESC EORP collected data.

INTRODUCTION: Infective endocarditis (IE) is associated with a high in-hospital and long term mortality. Although progress has been made in diagnostic approach and management of IE, morbidity and mortality of IE remain high. In the latest European guidelines, the importance of the multi-modality imaging in diagnosis and follow up of IE is emphasized. AIM: The aim was to provide information regarding mortality and adverse events of IE, to determine IE characteristics and to assess current use of imaging in the diagnostic workup of IE. METHODS: This is a prospective observational cohort study. We used data from the EURO-ENDO registry. Seven hospitals in the Netherlands have participated and included patients with IE between April 2016 and April 2018. RESULTS: A total of 139 IE patients were included. Prosthetic valve endocarditis constituted 32.4% of the cases, cardiac device related IE 7.2% and aortic root prosthesis IE 3.6%. In-hospital mortality was 14.4% (20 patients) and one-year mortality was 21.6% (30 patients). The incidence of embolic events under treatment was 16.5%, while congestive heart failure or cardiogenic shock occurred in 15.1% of the patients. Transthoracic and transoesophageal echocardiography were performed most frequently (97.8%; 81.3%) and within 3 days after IE suspicion, followed by 18F­fluorodeoxyglucose positron emission tomography/computed tomography (45.3%) within 6 days and multi-slice computed tomography (42.4%) within 7 days. CONCLUSION: We observed a high percentage of prosthetic valve endocarditis, rapid and extensive use of imaging and a relatively low in-hospital and one-year mortality of IE in the Netherlands. Limitations include possible selection bias.

Intramyocardial bone marrow cell injection does not lead to functional improvement in patients with chronic ischaemic heart failure without considerable ischaemia.

BACKGROUND: It has been suggested that bone marrow cell injection may have beneficial effects in patients with chronic ischaemic heart disease. However, previous trials have led to discrepant results of cell-based therapy in patients with chronic heart failure. The aim of this study was to evaluate the efficacy of intramyocardial injection of mononuclear bone marrow cells in patients with chronic ischaemic heart failure with limited stress-inducible myocardial ischaemia. METHODS AND RESULTS: This multicentre, randomised, placebo-controlled trial included 39 patients with no-option chronic ischaemic heart failure with a follow-up of 12 months. A total of 19 patients were randomised to autologous intramyocardial bone marrow cell injection (cell group) and 20 patients received a placebo injection (placebo group). The primary endpoint was the group difference in change of left ventricular ejection fraction, as determined by single-photon emission tomography. On follow-up at 3 and 12 months, change of left ventricular ejection fraction in the cell group was comparable with change in the placebo group (P = 0.47 and P = 0.08, respectively). Also secondary endpoints, including left ventricle volumes, myocardial perfusion, functional and clinical parameters did not significantly change in the cell group as compared to placebo. Neither improvement was demonstrated in a subgroup of patients with stress-inducible ischaemia (P = 0.54 at 3­month and P = 0.15 at 12-month follow-up). CONCLUSION: Intramyocardial bone marrow cell injection does not improve cardiac function, nor functional and clinical parameters in patients with severe chronic ischaemic heart failure with limited stress-inducible ischaemia. CLINICAL TRIAL REGISTRATION: NTR2516.

Longitudinal echocardiographic and clinical follow-up of patients undergoing mitral valve surgery without concomitant tricuspid valve repair.

BACKGROUND: In patients with mild to moderate functional tricuspid regurgitation (TR) and absence of right ventricular dysfunction or tricuspid annulus (TA) dilatation, there is currently no indication for concomitant tricuspid valve (TV) repair during elective mitral valve (MV) surgery. However, long-term results are conflicting. Here, we sought to determine the clinical outcome of this cohort, the rate of TR progression after MV surgery and the role of MV aetiology. METHODS: Patients for elective MV surgery without concomitant TV repair were retrospectively analysed with longitudinal echocardiographic and clinical follow-up, focusing on TR progression and MV aetiology. Linear regression analysis was performed for change in TR at follow-up, using pre-determined variables and confounders. RESULTS: In total 204 patients without TV repair were analysed. Development of more than moderate TR after a median of 3.1 [1.6-4.6] years was rarely seen: only in 2 out of 161 patients (1.2%) with known TR grade at follow-up. Overall, median preoperative and late postoperative TR grade were equal (p = 0.116). Subanalysis showed no significant difference in MV aetiology subgroups. Preoperative TR grade and male gender were inversely correlated to change in TR. Mortality was not influenced by the 1­year postoperative TR severity. CONCLUSION: Our data showed that in a study population of patients with mild to moderate TR undergoing MV surgery without concomitant TV repair, significant late TR was rarely seen. Based on our study, it is safe to waive concomitant TV repair in this specific patient cohort.

Haemodynamic and functional consequences of the iatrogenic atrial septal defect following Mitraclip therapy.

Percutaneous MitraClip placement for treatment of severe mitral regurgitation in high surgical risk patients is a commonly performed procedure and requires a transseptal puncture to reach the left atrium. The resulting iatrogenic atrial septal defect (iASD) is not routinely closed, yet the haemodynamic and functional consequences of a persisting defect are not fully understood. Despite positive effects such as acute left atrial pressure relief, persisting iASDs are associated with negative consequences, namely significant bidirectional shunting and subsequent worse clinical outcome. Percutaneous closure of the iASD may therefore be desirable in selected cases. In this review we discuss the available literature on this matter.

Carcinoid heart disease: a guide for screening and timing of surgical intervention.

The cardiac manifestations of a neuroendocrine tumour are referred to as carcinoid heart disease (CaHD) and are associated with a poor prognosis. Surgical intervention is the only proven therapeutic option and may prolong survival and quality of life. No consensus has been reached internationally with regard to screening for CaHD and the optimal timing for surgery. Although limited evidence is available on this matter, a trend towards early surgery and subsequent reduced mortality has been observed. In this review we provide an overview of the current understanding and propose a protocol to guide cardiologists in the screening for CaHD and the timing of referral to a specialised surgical centre.

Multimodality infarct identification for optimal image-guided intramyocardial cell injections.

BACKGROUND: Intramyocardial cell injections in the context of cardiac regenerative therapy can currently be performed using electromechanical mapping (EMM) provided by the NOGA®XP catheter injection system. The gold standard technique to determine infarct size and location, however, is late gadolinium enhanced magnetic resonance imaging (LGE-MRI). In this article we describe a practical and accurate technique to co-register LGE-MRI and NOGA®XP datasets during the injection procedures to ultimately perform image-guided injections to the border zone of the infarct determined by LGE-MRI. MATERIALS AND METHODS: LGE-MRI and EMM were obtained in three pigs with chronic myocardial infarction. MRI and EMM datasets were registered using the in-house developed 3D CartBox image registration toolbox consisting of three steps: 1) landmark registration, 2) surface registration, and 3) manual optimization. The apex and the coronary ostia were used as landmarks. RESULTS: Image registration was successful in all datasets, and resulted in a mean registration error of 3.22 ± 1.86 mm between the MRI surface mesh and EMM points. Visual assessment revealed that the locations and the transmural extent of the infarctions measured by LGE-MRI only partly overlap with the infarct areas identified by the EMM parameters. CONCLUSIONS: The 3D CartBox image registration toolbox enables registration of EMM on pre-procedurally acquired MRI during the catheter injection procedure. This allows the operator to perform real-time image-guided cell injections into the border zone of the infarct as assessed by LGE-MRI. The 3D CartBox thereby enables, for the first time, standardisation of the injection location for cardiac regenerative therapy.

Assessment of LV ejection fraction using real-time 3D echocardiography in daily practice: direct comparison of the volumetric and speckle tracking methodologies to CMR.

AIMS: This study is the first to directly compare two widely used real-time 3D echocardiography (RT3DE) methods of cardiac magnetic resonance imaging (CMR) and assess their reproducibility in experienced and less experienced observers. METHODS: Consecutive patients planned for CMR underwent RT3DE within 8 h of CMR with Philips (volumetric method) and Toshiba Artida (speckle tracking method). Left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were measured using RT3DE, by four trained observers, and compared with CMR values. RESULTS: Thirty-five patients were included (49.7 ± 15.7 years; 55 % male), 30 (85.7 %) volumetric and 27 (77.1 %) speckle tracking datasets could be analysed. CMR derived LVEDV, LVESV and LVEF were 198 ± 58 ml, 106 ± 53 ml and 49 ± 15 %, respectively. LVEF derived from speckle tracking was accurate and reproducible in all observers (all intra-class correlation coefficients (ICC) > 0.86). LVEF derived from the volumetric method correlated well to CMR in experienced observers (ICC 0.85 and 0.86) but only moderately in less experienced observers (ICC 0.58 and 0.77) and was less reproducible in these observers (ICC = 0.55). Volumes were significantly underestimated compared with CMR (p < 0.001). CONCLUSION: This study demonstrates that both RT3DE methodologies are sufficiently accurate and reproducible for use in daily practice. However, experience importantly influences the accuracy and reproducibility of the volumetric method, which should be considered when introducing this technique into clinical practice.

The role of exercise echocardiography in the management of mitral valve disease.

PURPOSE: Exercise echocardiography can assess the dynamic component of mitral valve (MV) disease and may therefore be helpful for the clinical decision-making by the heart team. The purpose of this study is to determine the role of exercise echocardiography in the management of disproportionately symptomatic or otherwise atypical patients with mitral regurgitation (MR) and stenosis (MS) in clinical practice. METHODS: Data of 14 MR and 14 MS patients, including echocardiograms at rest, were presented retrospectively to an experienced heart team to determine treatment strategy. Subsequently, exercise echo data were provided whereupon once again the treatment strategy was determined. This resulted in: value of exercise echo by means of 1) alteration or 2) confirmation of treatment strategy or 3) no additional value. RESULTS: During exercise the echocardiographic severity of MV disease increased in 9 (64 %) MR and 8 (57 %) MS patients. Based upon alteration or confirmation of the treatment strategy, the value of exercise echocardiography in the management of MR and MS was 86 % and 57 %, respectively. CONCLUSION: This study showed that physical exercise echo can have an important role in the clinical decision-making of challenging patients with MV disease. Exercise echocardiography had additional value to the treatment strategy in 71 % of these patients.

Current state of artificial intelligence-based algorithms for hospital admission prediction in patients with heart failure: a scoping review.

Aims: Patients with congestive heart failure (HF) are prone to clinical deterioration leading to hospital admissions, burdening both patients and the healthcare system. Predicting hospital admission in this patient group could enable timely intervention, with subsequent reduction of these admissions. To date, hospital admission prediction remains challenging. Increasing amounts of acquired data and development of artificial intelligence (AI) technology allow for the creation of reliable hospital prediction algorithms for HF patients. This scoping review describes the current literature on strategies and performance of AI-based algorithms for prediction of hospital admission in patients with HF. Methods and results: PubMed, EMBASE, and the Web of Science were used to search for articles using machine learning (ML) and deep learning methods to predict hospitalization in patients with HF. After eligibility screening, 23 articles were included. Sixteen articles predicted 30-day hospital (re-)admission resulting in an area under the curve (AUC) ranging from 0.61 to 0.79. Six studies predicted hospital admission over longer time periods ranging from 6 months to 3 years, with AUC's ranging from 0.65 to 0.78. One study prospectively evaluated performance of a disposable sensory patch at home after hospitalization which resulted in an AUC of 0.89 for unplanned hospital admission prediction. Conclusion: AI has the potential to enable prediction of hospital admission in HF patients. Improvement of data management, adding new data sources such as telemonitoring data and ML models and prospective and external validation of current models must be performed before clinical applicability is possible.

Cardiomyocyte progenitor cell-derived exosomes stimulate migration of endothelial cells.

Patients suffering from heart failure as a result of myocardial infarction are in need of heart transplantation. Unfortunately the number of donor hearts is very low and therefore new therapies are subject of investigation. Cell transplantation therapy upon myocardial infarction is a very promising strategy to replace the dead myocardium with viable cardiomyocytes, smooth muscle cells and endothelial cells, thereby reducing scarring and improving cardiac performance. Despite promising results, resulting in reduced infarct size and improved cardiac function on short term, only a few cells survive the ischemic milieu and are retained in the heart, thereby minimizing long-term effects. Although new capillaries and cardiomyocytes are formed around the infarcted area, only a small percentage of the transplanted cells can be detected months after myocardial infarction. This suggests the stimulation of an endogenous regenerative capacity of the heart upon cell transplantation, resulting from release of growth factor, cytokine and other paracrine molecules by the progenitor cells--the so-called paracrine hypothesis. Here, we focus on a relative new component of paracrine signalling, i.e. exosomes. We are interested in the release and function of exosomes derived from cardiac progenitor cells and studied their effects on the migratory capacity of endothelial cells.

Obstructive sleep apnoea is associated with impaired pictorial memory task acquisition and retention in children.

The aim of our study was to evaluate whether obstructive sleep apnoea (OSA) is associated with impaired acquisition and recall of a pictorial-based memory tasks in children. 54 children with OSA and 17 controls matched for age, sex and ethnicity underwent a sleep study (overnight polysomnogram). Before the sleep study subjects completed a 15-min pictorial memory task acquisition consisting of four trials, followed by a free-recall period to assess retention after 10 min and the following morning upon awakening. Children with OSA had a higher obstructive apnoea/hypopnoea index (6.3+/-1.5 events.h(-1) TST) than controls (0.6+/-0.1 events.h(-1) TST) (p<0.0001). Mean learning scores in controls over the four consecutive trials were incrementally better than in children with OSA for the four-trial set (p<0.0001). Both immediate (p<0.0001) and overnight recall performances were worse among OSA children (p<0.0001), who also exhibited declines in recall performance that was absent in controls (p<0.001). Differences in pictorial task acquisition trajectories suggest that children with OSA require more time and an increased number of learning opportunities to reach immediate and long-term recall performances that are reduced compared with controls. Thus, both acquisition and retention of newly learned material are compromised. These findings confirm and expand on the presence of known cognitive deficits in children with OSA.

Stem cell therapy for end-stage heart failure: indispensable role for the cell?

PURPOSE OF REVIEW: For heart failure patients, the urgent need for heart transplantation exceeds the availability of donor hearts. Therefore, cell transplantation has emerged as an interesting and potential solution. This review will focus on the capability of different types of stem cells to regenerate the heart. Moreover, the mechanism for success will be addressed, focusing on the specific (and indispensable?) role of the cells. RECENT FINDINGS: In recent years, many types of stem cells have been described as a possible source for cell transplantation in failing hearts, with mixed outcomes. Cell transplantation is hampered by suboptimal delivery techniques, limited survival of cells, and reduced proliferation and differentiation rates in vivo. Interestingly, the number of injected cells that engrafted the heart successfully cannot explain the observed beneficial effects and, therefore, paracrine effects are suggested for the success in cell therapy. SUMMARY: This review summarizes the current types of stem or progenitor cells used in cardiac cell therapy and beneficial effects on heart function and morphology in preclinical studies. Currently, the observed effects suggest that paracrine effects might be responsible, thereby triggering mobilization and activation of resident (stem) cells, which challenges the classical concept and true regenerative capacity of cell therapy at this point.

Cell therapy for ischaemic heart disease: focus on the role of resident cardiac stem cells.

Myocardial infarction results in loss of cardiomyocytes, scar formation, ventricular remodelling, and eventually heart failure. In recent years, cell therapy has emerged as a potential new strategy for patients with ischaemic heart disease. This includes embryonic and bone marrow derived stem cells. Recent clinical studies showed ostensibly conflicting results of intracoronary infusion of autologous bone marrow derived stem cells in patients with acute or chronic myocardial infarction. Anyway, these results have stimulated additional clinical and pre-clinical studies to further enhance the beneficial effects of stem cell therapy. Recently, the existence of cardiac stem cells that reside in the heart itself was demonstrated. Their discovery has sparked intense hope for myocardial regeneration with cells that are obtained from the heart itself and are thereby inherently programmed to reconstitute cardiac tissue. These cells can be detected by several surface markers (e.g. c-kit, Sca-1, MDR1, Isl-1). Both in vitro and in vivo differentiation into cardiomyocytes, endothelial cells and vascular smooth muscle cells has been demonstrated, and animal studies showed promising results on improvement of left ventricular function. This review will discuss current views regarding the feasibility of cardiac repair, and focus on the potential role of the resident cardiac stem and progenitor cells. (Neth Heart J 2009;17:199-207.).

A young woman with a severe bilateral pneumonia as the presenting sign of an adrenal carcinoma.

A severe bilateral, culture-negative pneumonia was diagnosed in a 22-year-old woman. Additional diagnostic procedures accidentally revealed a large adrenal carcinoma and hypercortisolism. The adrenal carcinoma was surgically removed, and she received mitotane treatment. This severe and life-threatening infection was the first sign of an immunosuppressive state as part of Cushing's syndrome due to the adrenal carcinoma.