Cardiac indexes in young subjects with and without bicuspid aortic valve.

OBJECTIVES: Bicuspid aortic valve (BAV) is a common congenital anomaly. The aeromedical implications of this condition are unclear. This study attempts to evaluate a possible association between BAV with or without aortic regurgitation (AR) and cardiac and aortic morphology in young healthy subjects. METHODS: Air force academy applicants undergo routine echocardiography as part of the screening process. All echocardiographic examinations performed in the years 2004-2011 were evaluated. Applicants in whom BAV was identified were divided into those with and without aortic regurgitation. Both groups were compared with an age-matched group of applicants in whom echocardiography was interpreted as normal. All M-mode parameters were compared between the three groups. RESULTS: There were 7042 echocardiographic examinations performed in the years 2004-2010 and 95 applicants (1.35%) were diagnosed with BAV. Of these, 34 applicants had AR (36%) and 61 had no AR. When compared with normal subjects, systolic blood pressure was higher in applicants with BAV (127 mmHg vs. 123 mmHg, P = 0.01). Aortic root diameter, left atrial diameter, left ventricular end systolic volume, interventricular septum thickness and posterior wall thickness were all increased in applicants with BAV compared with applicants without BAV. In those with BAV, no statistically significant differences in M-mode characteristics were noted between applicants with and without aortic regurgitation. CONCLUSIONS: BAV in young healthy subjects may influence cardiac morphology irrespective of the presence of aortic regurgitation. Aeromedical disposition for patients with BAV should be based on the presence of the condition and not on the presence of AR, considering the AR is of a mild or minimal degree.

Acceleration forces and cardiac and aortic indexes in jet fighter pilots.

BACKGROUND: Military jet fighter pilots are exposed to acceleration (+G(z)) forces which possibly influence various cardiac parameters. Several previous studies have evaluated the impact of exposure to acceleration forces on cardiac morphology and function, but these studies were not prospective and were either based on small samples or compared jet fighter pilots with pilots of low-performance aircraft. The purpose of this study was to evaluate the effect of acceleration forces on cardiac morphologic changes in jet fighter pilots. METHODS: Routine echocardiography has been performed for jet fighter pilots since 2003. Medical records of all military jet fighter pilots who underwent echocardiography following 2003 were retrospectively evaluated. Of those, all jet fighter pilots who underwent an additional echocardiography prior to 2003 were identified. Echocardiographic parameters were recorded using M-mode and included left ventricular diameter at end systole and end diastole, interventricular septum thickness, thickness of the posterior wall, aortic root diameter and aortic valve opening, diameter of the left atrium, and left ventricular mass. Medical records of the subjects were evaluated for development of adverse events. RESULTS: There were 72 subjects who underwent 2 echocardiographic examinations with a mean follow-up period of 8.92 yr. Subjects were 18-50 yr old at the time of the initial echocardiographic examination. All parameters evaluated by M-mode were not significantly changed from the baseline examination. No adverse events occurred during the follow-up period. DISCUSSION: Findings of this study suggest that exposure to acceleration forces is not associated with cardiac and aortic morphologic changes.

Physical examination and ECG screening in relation to echocardiography findings in young healthy adults.

BACKGROUND AND AIMS: Cardiovascular screening in young adults is an important tool in many occupational settings. Our aim was to test whether screening physical examination and ECG influence the rate of abnormal echocardiogarphic findings in young healthy subjects. METHODS: Consecutive echocardiography results of 18- to 20-year-old flight candidates were analyzed retrospectively. Echocardiographies were performed as part of a screening protocol, which includes ECG, physical examination and referral for echocardiography for any positive finding. A second stage includes universal echocardiography for all candidates. RESULTS: 1,066 subjects were evaluated; 489 subjects underwent echocardiography following referral because of abnormal auscultatory or ECG findings. Findings (mostly mild valvular insufficiencies) were demonstrated in 12.7%, with only 0.6% of subjects disqualified. In subjects who underwent universal echocardiography (n = 577), findings (mostly mild valvular insufficiencies) were detected in 18%, with only 0.5% of subjects disqualified. CONCLUSIONS: The rate of significant echocardiography findings is extremely low in this young and healthy population. The presence of abnormal findings on either physical examination or ECG screening was not demonstrated to alter the rate of abnormal echocardiographic findings. We suggest that the low yield of screening should be weighed against the cost of an unidentified congenital cardiac lesion in the specific setting.

Effect of G-force on bicuspid aortic valve in aviators.

BACKGROUND AND AIMS: Bicuspid aortic valve (BAV) is a common congenital cardiac malformation. The major complications are aortic stenosis (AS), aortic regurgitation (AR), infectious endocarditis and aortic dissection. This paper aims to assess the hemodynamic importance of incidentally-found BAV in military aviators and evaluate the effect of high G-force on disease progression. METHODS: Aviators with BAV were detected by reviewing all cardiac assessment records between 1987 and 2005. All aviators underwent annual flight surgeon examination. Echocardiography was performed as recommended by our cardiologists and flight surgeons. RESULTS: Eight newly diagnosed cases of BAV were found. All of the aviators continued active aviation throughout the study period. Repeat echocardiography demonstrated progressive widening of the aortic diameter in five of the eight aviators. No worsening of valve dysfunction was seen in those with mild aortic regurgitation at diagnosis. Left ventricular dimensions and function did not deteriorate. No new valve complications, including infectious endocarditis, were seen. The age at diagnosis strongly correlated with the root diameter change; both total (r = 0.74, p = 0.02) and annualized (r = 0.78, p = 0.02) change. Over a mean follow-up period of 12.1 years, no difference was seen in the progression of BAV in high-performance as compared to low-performance aviators. CONCLUSIONS: Exposure to G-force and anti-G maneuvers does not appear to worsen cardiac and valve function in aviators with BAV.

Quadrivalvular heart disease: transition from congenital pulmonary stenosis to rheumatic disease.

The case is reported of a 36-year-old male patient suffering from congenital pulmonary stenosis who previously had undergone pulmonary balloon valvuloplasty. During the past nine years, he had experienced recurrent attacks of rheumatic fever that gradually damaged all four heart valves. The patient underwent aortic, mitral and pulmonary valve replacement with tricuspid valve annuloplasty and pulmonary artery reconstruction. Histologically, all heart valves--including the pulmonary--had similar changes that corresponded to chronic rheumatic disease.

BNP in septic patients without systolic myocardial dysfunction.

BACKGROUND: We tested our hypothesis that serum BNP levels rise in sepsis and septic shock patients as a result of an inflammatory state and not only because of left ventricular dysfunction. METHODS: Twenty-one patients with sepsis or septic shock were enrolled in the study. Echocardiography was performed in every patient on admission and at discharge. Laboratory data were evaluated on admission, during hospitalization, and at discharge. Serum IL-1beta, IL-6, TNFalpha, and BNP concentrations were determined. RESULTS: BNP values on admission (r=0.47, p=0.03), during hospitalization (r=0.64, p=0.014), and on the day of discharge (r=0.54, p=0.015) were all positively correlated with CRP values. Mean BNP (r=0.07, p=0.006) and BNP level at discharge (r=0.68, p=0.001) were also positively associated with IL-1 at discharge. Mean CRP (17.7 mg/dL+/-1.5 vs. 9.2 mg/dL+/-3.6, p=0.002), IL-6 (46.6 pg/mL+/-2.2 vs. 25.6 pg/mL+/-16.3, p=0.003), and SAPS II levels (41.3+/-4.7 vs. 33.9+/-6.5 p=0.01) were also higher in patients who died versus those who survived. No difference in BNP levels was recorded in subjects who died versus those who survived. There was no clinical or echocardiographic evidence of left ventricular systolic dysfunction (mean EF% on admission 55.1+/-21.7 vs. 61.3+/-8.6 on discharge, p=0.123). Serum BNP levels at discharge were inversely associated with EF values on admission (r=-0.475, p=0.046) and positively associated with E/A ratio on admission (r=0.565, p=0.028). No association was found between BNP values and death. CONCLUSION: BNP is positively correlated with CRP levels in septic patients without clinical or echocardiographic evidence of systolic dysfunction. No association was found between death and BNP values. It seems that, in septic patients, BNP is less accurate as a measure of ventricular dysfunction.

Adiponectin as an independent predictor of left ventricular hypertrophy in nondiabetic patients with hypertension.

We evaluated novel and traditional biomarkers as well as hemodynamic parameters associated with the development of left ventricular hypertrophy (LVH) in nondiabetic patients with hypertension. Nondiabetic patients with hypertension (n = 86) were evaluated for lipids, glucose, insulin, homeostasis model assessment-insulin resistance (HOMA-IR), adiponectin, aldosterone, renin, matrix metalloproteinase 2, and endothelin. Arterial elasticity was evaluated using pulse wave contour. The LVH parameters were assessed echographically. Adiponectin was significantly and inversely associated with left ventricular mass (LVM; P = .032). The aldosterone-renin ratio (ARR) was significantly, positively associated with LVM (P = .031). Fasting insulin as well as HOMA-IR was significantly, positively associated with LVM (P = .036 and P = .025, respectively). In multiple linear regression analysis, adiponectin and ARR remained a significant predictor of LVM. The present study found that adiponectin and ARR are important independent determinants of LVH in nondiabetic patients with hypertension.

Comparison of effectiveness of angiotensin-converting enzyme inhibitors after acute myocardial infarction in diabetic versus nondiabetic patients.

Mortality and morbidity after acute myocardial infarction (AMI) is higher in diabetic than in nondiabetic patients. Angiotensin-converting enzyme (ACE) inhibitors have been shown to exert a beneficial effect after AMI. We sought to evaluate the association between treatment with ACE inhibitors and 1-year outcome after AMI in diabetic and nondiabetic patients in a national survey. The study population was drawn from a national survey conducted in all coronary care units operating in Israel during a 5-month period in 1996, and included 2,179 patients with AMI: 533 diabetics (24%), 322 of whom received ACE inhibitors (60%) and 211 who did not; and 1,646 nondiabetics, 805 of whom received ACE inhibitors and 841 who did not. In both groups of patients, those treated with ACE inhibitors were older, included more women, more had a history of AMI, anterior wall AMI, or hypertension, and more had worse Killip class on admission. Diabetic patients treated with ACE inhibitors experienced lower 1-year mortality rates than diabetics not treated with ACE inhibitors (16.2% vs 18.8%, respectively; covariate adjusted hazard ratio 0.47, 95% confidence interval 0.30 to 0.74). In nondiabetic patients, however, ACE inhibitor treatment was not associated with a better outcome (10.2% vs 7.3%, respectively; covariate adjusted hazard ratio 0.80; 95% confidence interval 0.56 to 1.15). Thus, treatment with ACE inhibitors after AMI appears to be particularly beneficial in diabetic patients. The beneficial effect observed supports the widespread use of ACE inhibitors in diabetic patients after AMI.

Anomalous origin of the left coronary artery from the pulmonary artery accompanied by mitral valve prolapse and regurgitation: Surgical implication of dobutamine stress echocardiography.

A young woman with bileaflet mitral valve prolapse and anomalous left coronary artery arising from the pulmonary artery, accompanied by significant mitral regurgitation (MR), underwent dobutamine stress echocardiography to assess the effect of anomalous left coronary artery arising from the pulmonary artery on MR severity. On the basis of the dobutamine stress echocardiography-induced ischemia, which exacerbated the degree of MR, a revascularization operation sparing the mitral valve was performed, resulting in significant improvement of the MR. We suggest that dobutamine stress echocardiography could be used to assess the relative contribution of each syndrome to the pathophysiology of MR, directing the surgical procedure.

Extension of adrenocortical carcinoma into the right atrium--echocardiographic diagnosis: a case report.

BACKGROUND: Adrenocortical carcinoma is a rare, highly malignant tumor. Cardiac involvement of the tumor is very rare. Echocardiography facilitates the evaluation of the cardiac involvement of the tumor. CASE PRESENTATION: We describe a patient with an adrenal tumor. Transthoracic echo showed its extension into the right atrium. Accordingly, a combined abdominal and cardiac operation was performed, monitored by transesophageal echocardiography. CONCLUSION: This case highlights the importance of echocardiography in revealing the cardiac involvement by this tumor and in planning the operative procedure.

The correlation between isolated interventricular septal hypertrophy and 24-h ambulatory blood pressure monitoring in apparently healthy air crew.

BACKGROUND: Interventricular septal (IVS) hypertrophy is considered to affect prognosis in hypertensive patients. However, the natural history of isolated septal hypertrophy, identified by echocardiography in otherwise healthy subjects is not well defined. METHODS: The study population included 51 apparently healthy pilots with septal hypertrophy (septal thickness > 11 mm) defined by routine echocardiography, with a calculated normal left ventricular (LV) mass. All pilots underwent casual blood pressure (BP) measurements and a 24-h ambulatory BP monitoring (ABPM). Hypertension (HTN) was defined as a casual measurement of > 140/90 mmHg. RESULTS: The mean age of the pilots was 38 +/- 11 years and the body mass index (BMI) 26.3 kg/m(2). The 17 pilots found to be hypertensive had a higher septal thickness than the 34 counterparts with normal BP measurements (13.8 +/- 2.0 mm versus 12.6 +/- 1.7 mm, P < 0.04, respectively). The mean ambulatory daytime systolic and diastolic BP were higher in comparison to non-hypertensive pilots (142 +/- 6.2 versus 128 +/- 5.0 mmHg, P < 0.0001 for systolic BP and 91 +/- 5.3 versus 78 +/- 4.1 mmHg, P = 0.001 for diastolic BP), respectively. The adjusted relative risk (RR) of a subject with an IVS thickness P > 12 mm to be hypertensive by ABPM was 3.12 (95% confidence interval 1.04-9.37, P < 0.02). CONCLUSIONS: Isolated IVS hypertrophy, even in the presence of normal LV mass is associated with HTN. Screening healthy subjects at risk for hypertension by echocardiography enables one to identify those who should be closely monitored, using among others, ABPM.

Presenting symptoms, admission electrocardiogram, management, and prognosis in acute coronary syndromes: differences by age.

In a nationwide survey conducted in all 26 hospitals in Israel during February and March 2000, data were collected on 2133 consecutive acute coronary syndrome patients. The patients were divided into three age subgroups: <65 years (n=974), 65-74 years (n=500), and > or =75 years (n=639). The frequency of no anginal pain/atypical symptoms on presentation increased with age for all acute coronary syndrome patients (14%, 21%, and 32%, in the three age subgroups, respectively; p for trend <0.0001). The frequency of ST-elevation on admission electrocardiogram decreased with advancing age (59%, 46%, and 42%, in the three age subgroups, respectively; p for trend <0.0001), whereas ST-depression gradually increased (14%, 24%, and 28%, respectively; p for trend <0.0001). In multivariate analysis, variables associated with no anginal pain/atypical symptoms on presentation (in decreasing order) were: history of heart failure, age, lack of past angina, diabetes, and nonsmoking. ST-elevation was inversely associated with no anginal pain/atypical symptoms on admission (odds ratio, 0.48; 95% confidence interval, 0.37-0.63). The use of acute reperfusion therapy significantly declined with advancing age. Seven-day, 30-day, and 1-year mortality increased with advancing age. No anginal pain/atypical symptoms on presentation were associated with an increased early and late mortality in all three age subgroups.

Persistent anemia in otherwise asymptomatic severe aortic stenosis: a possible indication for valve replacement?

BACKGROUND: The indication for aortic valve replacement in patients with significant aortic stenosis is symptomatology. Aortic stenosis may be associated with bleeding from colonic angiodysplasia, resulting in anemia. Persistent anemia in such patients, despite lack of an identifiable source of bleeding, is not considered an indication for valve replacement. OBJECTIVES: To report our experience with two elderly female patients who suffered from severe asymptomatic aortic stenosis, low levels of large von Willebrand factor multimer (10% and 5% respectively) and persistent anemia requiring multiple blood transfusions. METHODS: Both patients underwent an intensive work-up, but a source of bleeding could not be identified. Aortic valve replacement was performed in both patients. RESULTS: Aortic valve replacement abolished the need for further blood transfusions during a follow-up period of 20 months with normalization of the vWF multimer level (20% and 30% respectively). CONCLUSION: We suggest that aortic valve replacement be considered in selected patients with severe, otherwise asymptomatic aortic stenosis, who suffer from persistent anemia requiring multiple blood transfusions, lack an identifiable source of bleeding and have low levels of large vWF multimers.

Echocardiographic evaluation and follow-up of cardiac and aortic indexes in aviators exposed to acceleration forces.

BACKGROUND: Military jet fighter pilots are routinely exposed to acceleration (+Gz) forces. This recurrent exposure may influence various cardiac parameters. A few previous studies have evaluated the impact of exposure to acceleration forces on cardiac morphology and function, but these studies were mostly based on small cohorts, and subjects did not undergo baseline echocardiographic examinations before +Gz exposure. METHODS: Ninety-six jet fighter pilots with high +Gz exposure underwent echocardiographic evaluation before and 7 to 12 years after repeated +Gz exposure. Echocardiographic parameters were recorded using M-mode echocardiography and included left ventricular diameter at end-systole and end-diastole, interventricular septal thickness, thickness of the posterior wall, aortic root diameter and aortic valve opening, diameter of the left atrium, and left ventricular mass. Medical records of the subjects identified were evaluated for the development of adverse events. RESULTS: The average age at the time of the initial echocardiographic examination was 19.2 years. All subjects were healthy, without cardiovascular risk factors, and had no prior exposure to acceleration forces. The average flying period on jet planes at the time of follow-up examination was 1,812 hours. The mean follow-up period was 9.13 years. All parameters evaluated by M-mode echocardiography were not significantly changed from the baseline examination. No adverse events occurred during the follow-up period. CONCLUSIONS: Exposure to acceleration forces has no significant impact on cardiac and aortic morphology.

Age differences in the adherence to treatment guidelines and outcome in patients with ST-elevation myocardial infarction.

The aim of this study was to assess age differences in the utilization of class-I treatment guidelines and its effect on mortality in patients with ST-elevation myocardial infarction (STEMI). The study included 1026 consecutive patients from the prospective nationwide Acute Coronary Syndrome Israeli Survey (ACSIS). Primary reperfusion was used less often among elderly (age>75 years) patients than among those aged 65-74 and <65 years (46%, 63%, 64%, respectively, p (for trend)=0.004). Class-I evidence-based medications (EBM) at discharge (aspirin, ß-blockers, angiotensin converting-enzyme inhibitors=ACEI, angiotensin receptor-blockers=ARBs and statins) were less frequently prescribed to elderly compared to younger age-subgroup (44%, 61%, 57%, respectively; adjusted odds ratio (OR)=0.62; 0.40-0.97 for age ≥ 75 vs. age<65 years). Early and 1-year mortality rates were 3-5-fold higher among the elderly compared to patients <65 years. In the entire cohort use of primary reperfusion was associated with lower 1-year mortality (OR=0.69; 0.47-1.01), as was the use of EBM (OR=0.26; 0.17-0.41). These effects were similar across all age-subgroups but with a greater impact among the elderly, as the number of patients needed to treat (NNT) was significantly lower with advancing age. Better adherence to treatment guidelines may improve the prognosis of elderly patients with STEMI.

Effects of repeated exposure to acceleration forces (+Gz) and anti-G manoeuvres on cardiac dimensions and performance.

Exposure to acceleration forces (+Gz) and anti-G protective manoeuvres causes changes in cardiac preload and afterload. These changes can result in cardiac hypertrophy or enlargement. Previous studies regarding the effect of acceleration in high-G aviators (HGAs) are few and inconclusive. An echocardiographic study was initiated to determine whether there are structural or functional cardiac differences between HGAs and low-G aviators (LGAs).The present study was a cross-sectional study in which echocardiographic parameters in HGAs were compared with those in LGAs. Both retrospective and prospective data were collected. Fifty aviators were included in each group. The aviators who participated in the present study were randomly chosen from a cohort with similar demographic characteristics and flying hours. No major differences were found in cardiac dimensions and function between HGAs and LGAs. The authors speculate that the reason why no major differences were found was due to the short period of total exposure to very high +Gz forces and anti-G measures.

Left ventricular ejection fraction assessment by Tl-201 gated SPECT: a comparison with echocardiography.

BACKGROUND: Few studies including only a limited number of patients have compared left ventricular ejection fraction (LVEF) assessed by 2-dimensional echocardiography (2-DE) and electrocardiography-gated Tl-201 single-photon emission computed tomography (SPECT). HYPOTHESIS: LVEF assessment by Tl-201 gated spect is comparable with LVEF assessed by 2-DE in two different echocardiographic laboratories. MATERIAL AND METHODS: Patients (n = 402) underwent Tl-201 gated SPECT in the same laboratory and 2-DE in 2 different laboratories. Patients were divided into 2 groups according to the study laboratory: group 1, at the tertiary hospital and group 2, at a community laboratory. RESULTS: LVEF evaluations were similar (mean LVEF: 50.73% +/- 11.67% by 2-DE vs 50.11% +/- 11.41% by SPECT in group 1 and 57.27% +/- 7.44% by 2-DE vs 57.41% +/- 8.37% by SPECT in group 2). All LVEF measurements were highly correlated (r = 0.7, P<.001). Baseline characteristics differed between the groups, with a higher prevalence of past myocardial infarction in the in-hospital vs the community echo group (46.7% vs 22.2%, P<.01), resulting in a higher LVEF in the latter, both by 2-DE (mean 50.7% +/- 11.7% vs 57.3% +/- 7.4%, P<.01) and SPECT (50.1% +/- 11.4% vs 57.4% +/- 8.4%, P<.01). CONCLUSIONS: The Tl-201 gated SPECT is a reliable clinical tool for LVEF assessment, with good correlation when compared to 2-DE. It may be routinely used as an alternative for patients with poor acoustic visualization and should be performed systematically in patients undergoing myocardial perfusion imaging with Tl-201.

Coronary angiography in the elderly with acute myocardial infarction.

BACKGROUND: Despite the high mortality rate in elderly patients with acute myocardial infarction (AMI), the value of coronary angiography (CA) in the elderly has been questioned due to a less favorable outcome. The aim of the study was to determine the prognostic significance of CA on mortality of elderly patients AMI in "real world" practice. METHODS: The study cohort comprised 1009 elderly (age > or = 75 years) patients with AMI who were derived from three prospective national surveys between 1996 and 2000 in all 25 CCUs operating in Israel. Baseline characteristics, hospital course, management and outcome of 274 (27%) elderly patients who underwent CA during the index hospitalization were compared with 735 (73%) counterpart patients who did not. RESULTS: Patients who underwent CA were on average 2.2 years younger, and were more often with hyperlipidemia (p<0.0001 for each) and with a history of previous percutaneous coronary intervention (p<0.03) than the control group. They had a more favorable clinical presentation: a higher systolic blood pressure (p<0.04), a better Killip class (p<0.03) and an increased frequency of non-Q wave MI (p<0.03). They developed more often recurrent MI (p=0.002) and re-ischemia (p<0.0001). Variables associated with CA use during the index hospitalization were re-infarction, re-ischemia, the year of the index AMI and the availability of an on-site a catheterization laboratory in the hospital, while a higher age and fibrinolytic therapy decreased the likelihood of CA use. Of the patients who underwent CA, 67% underwent coronary revascularization (either PCI and/or CABG). Crude and adjusted mortality rates at 1 year were significantly lower in patients who underwent CA, as compared to counterparts who did not: 21% vs. 37.3%, respectively (p<0.0001), hazard ratio=0.52 (95% confidence interval 0.38-0.71). The benefit of CA was noted in a wide range of subgroups analyzed. CONCLUSIONS: In "real world" practice, elderly patients with AMI who undergo CA during hospitalization have a better prognosis at 1 year. Age alone should not be a deterrent to performing CA in elderly patients with AMI. Further large randomized trials are needed to confirm that an invasive approach is beneficial in high-risk elderly patients with AMI. CONDENSED ABSTRACT: To determine the prognostic significance of coronary angiography (CA) during the course of acute myocardial infarction (AMI) in "real world" practice on mortality of elderly patients, 1009 such patients were studied. Re-infarction, re-ischemia, the year of the index AMI and the availability of an on-site a Cath. Lab. were variables which increased the likelihood of undergoing CA, while a higher age and fibrinolytic therapy decreased this likelihood. The crude and covariate adjusted mortality rates at 1 year were significantly lower in patients who underwent CA in comparison to counterparts who did not: 21% vs. 37.3%, respectively (p<0.0001), hazard ratio 0.52 (95% confidence interval 0.38-0.71). The benefit of CA was noted across a wide range of subgroups analyzed.

First report of prosthetic mitral valve endocarditis due to Corynebacterium striatum: Successful medical treatment. Case report and literature review.

A rare case of prosthetic mitral valve endocarditis due to Corynebacterium striatum, treated medically, is reported. While this organism has been described in a few cases of native valve endocarditis, only two cases of prosthetic aortic valve endocarditis have been reported. We herewith report the first case of successful medical treatment of prosthetic mitral valve endocarditis due to C. striatum, emphasizing the complicated clinical course and reviewing the literature regarding diagnosis and therapeutical approach.

Safety of cardiac rehabilitation in a medically supervised, community-based program.

The time to occurrence of cardiovascular complications after the beginning of an exercise rehabilitation program is variable. It is not clear whether such complications are related to the duration in the program. The aim of the present study was to assess the timing of cardiovascular events occurring during the activity and the long-term safety of a medically supervised cardiac rehabilitation program performed in the community, in a large cohort. We retrospectively evaluated 3,511 patients with a history of myocardial infarction, coronary artery bypass grafting and risk factors for coronary artery disease, participating in exercise training, for 69 months. The total number of patient-hours was 338,688 with an event rate of 1/58,902 patient-hours/year (0.02%). Non-fatal events occurred in 11 patients and fatal cardiovascular events in 2 patients; 1 was successfully resuscitated. Most of the non-fatal events (62%) occurred during the first 4 weeks from the beginning of the exercise program. One third of the patients who experienced cardiovascular events, resumed the exercise program with no further complications. Medically supervised cardiac rehabilitation program is accompanied by a very low incidence of cardiovascular events. Nevertheless, special caution should be undertaken during the first sessions of the program.