Simplified risk stratification criteria for identification of patients with MRSA bacteremia at low risk of infective endocarditis: implications for avoiding routine transesophageal echocardiography in MRSA bacteremia.

The aim of this study was to identify patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with low risk of infective endocarditis (IE) who might not require routine trans-esophageal echocardiography (TEE). We retrospectively evaluated 398 patients presenting with MRSA bacteremia for the presence of the following clinical criteria: intravenous drug abuse (IVDA), long-term catheter, prolonged bacteremia, intra-cardiac device, prosthetic valve, hemodialysis dependency, vertebral/nonvertebral osteomyelitis, cardio-structural abnormality. IE was diagnosed using the modified Duke criteria. Of 398 patients with MRSA bacteremia, 26.4 % of cases were community-acquired, 56.3 % were health-care-associated, and 17.3 % were hospital-acquired. Of the group, 44 patients had definite IE, 119 had possible IE, and 235 had a rejected diagnosis. Out of 398 patients, 231 were evaluated with transthoracic echocardiography (TTE) or TEE. All 44 patients with definite IE fulfilled at least one criterion (sensitivity 100 %). Finally, a receiver operator characteristic (ROC) curve was obtained to evaluate the total risk score of our proposed criteria as a predictor of the presence of IE, and this was compared to the ROC curve of a previously proposed criteria. The area under the ROC curve for our criteria was 0.710, while the area under the ROC curve for the criteria previously proposed was 0.537 (p < 0.001). The p-value for comparing those 2 areas was less than 0.001, indicating statistical significance. Patients with MRSA bacteremia without any of our proposed clinical criteria have very low risk of developing IE and may not require routine TEE.

How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage?

STUDY OBJECTIVES: To identify the risk of thromboembolism after withholding or reversing the effect of warfarin therapy following a major hemorrhage. DESIGN: Retrospective medical record review. SETTING: Tertiary-care hospital. PATIENTS: Twenty-eight patients with prosthetic heart valves receiving warfarin were hospitalized for major hemorrhage from 1990 to 1997. The mean +/- SD age was 61 +/- 11 years (15 men and 13 women). Twenty patients had St. Jude valves, 4 patients had Carpentier-Edwards bioprosthetic valves, 2 patients had Starr Edwards valves, and 2 patients had Bjork-Shiley valves. Valves were in the mitral position in 12 patients, the aortic position in 12 patients, and both mitral and aortic positions in 4 patients. The average interval from valve surgery to index bleeding was 7 years. Twenty-five patients had GI or retroperitoneal hemorrhage, 2 patients had an intracranial hemorrhage, and 1 patient had a subdural hematoma. INTERVENTIONS: Vitamin K was administered to five patients and fresh frozen plasma was given to seven patients to reverse anticoagulation. The mean duration of anticoagulation withholding was 15 +/- 4 days. MEASUREMENTS AND RESULTS: None of the patients had thromboembolic complications. There were four in-hospital deaths. Twenty-two of the 24 hospital survivors resumed warfarin therapy at hospital discharge. At 6-month follow-up, 10 of 19 patients remaining on warfarin therapy had recurrent GI bleeding. CONCLUSIONS: Thromboembolic risk is low in prosthetic heart valve patients hospitalized with major hemorrhage when their warfarin therapy is reversed or withheld. Recurrent bleeding within 6 months of the resumption of anticoagulation is common, and aggressive treatment of the bleeding source and the risk-benefit ratio of continued anticoagulation need to be considered.

Primary right atrial angiosarcoma mimicking acute pericarditis, pulmonary embolism, and tricuspid stenosis.

A 29 year old white man presented to the emergency room with new onset pleuritic chest pain and shortness of breath. He was initially diagnosed as having viral pericarditis and was treated with non-steroidal anti-inflammatory drugs. A few weeks later he developed recurrent chest pain with cough and haemoptysis. Chest radiography, cardiac examination, transthoracic and transoesophageal echocardiography pointed to a mass that arose from the posterior wall of the right atrium, not attached to the interatrial septum, which protruded into the lumen of the right atrium causing intermittent obstruction of inflow across the tricuspid valve. Contrast computed tomography of the chest showed a right atrial mass extending to the anterior chest wall. The lung fields were studded with numerous pulmonary nodules suggestive of metastases. A fine needle aspiration of the pulmonary nodule revealed histopathology consistent with spindle cell sarcoma thought to originate in the right atrium. Immunohistochemical stains confirmed that this was an angiosarcoma. There was no evidence of extracardiac origin of the tumour. The patient was treated with chemotherapy and radiation. This case highlights the clinical presentation, rapid and aggressive course of cardiac angiosarcomas, and the diagnostic modalities available for accurate diagnosis.

Patent ductus arteriosus in elderly patients: clinical and echocardiographic features-a case-based review.

Congenital heart disease in adults is a rapidly growing field, with many operated and unoperated infants and children surviving into adulthood. Patent ductus arteriosus is an example of a congenital cardiac defect, which may enable patients to survive well into adulthood without prior recognition or correction before symptoms arise. This case illustrates the clinical and echocardiographic manifestations of patent ductus arteriosus with special emphasis on its 2-dimensional and Doppler findings. Management options for this condition are also briefly addressed.

Abnormal implantation of permanent pacemaker lead in the left ventricle via a patent foramen ovale: clinical and echocardiographic recognition of a rare complication.

An 84-year-old man with a history of permanent pacemaker placement had a preoperative cardiac evaluation for prostate cancer surgery. The patient was asymptomatic, and the results of a physical examination were consistent with a right bundle branch block, which was confirmed by electro-cardiogram as his paced rhythm. A chest radiograph raised the possibility of an abnormal lead location, and transthoracic echocardiography confirmed the mechanism of an abnormal placement of the pacemaker lead. Left ventricular location of pacemaker is rare, and awareness of its clinical and imaging findings, complications, and management options is important for clinicians involved in the care of patients with pacemakers.

Giant left atrium secondary to tight mitral stenosis leading to acquired Lutembacher syndrome: a case report with emphasis on role of echocardiography in assessment of Lutembacher syndrome.

Lutembacher syndrome is an unusual clinical entity of congenital secundum atrial septal defect in combination with rheumatic mitral stenosis. Although this classic form is seldom seen by the adult cardiologist, spontaneous Lutembacher syndrome as discussed later or the iatrogenic variant is not infrequently encountered. The pathophysiologic, clinical, and hemodynamic differences of mitral valve disease in the presence of atrial septal defect compared with isolated mitral stenosis are highlighted in this case review. Special emphasis has also been given to echocardiographic evaluation of this syndrome complex, particularly in the setting of percutaneous mitral valvuloplasty, which produces the iatrogenic form of Lutembacher syndrome.

Racial differences in patients with heart failure.

BACKGROUND AND HYPOTHESIS: Limited data exist regarding racial differences in heart failure. The objective of this prospective study was to document racial differences in the baseline demographics and patterns of health care utilization and outcomes in patients with heart failure. METHODS: The data on 163 consecutive patients (113 black, 50 white) admitted with a diagnosis of heart failure confirmed by pulmonary congestion on chest x-ray were prospectively evaluated. Patient demographics, physical examination findings at admission, comorbid conditions, and medications at admission and discharge were analyzed. Follow-up was performed to document visits to the physician's office after discharge and readmission rate during a 6-month time period. RESULTS: Compared with whites, blacks were younger in age (mean age 63.8 +/- 13.7 years vs. 70.8 +/- 13.1, p = 0.003), and had a higher prevalence of hypertension (86 vs. 66%, p = 0.004), left ventricular hypertrophy (24 vs. 8%, p = 0.02), ejection fraction < 40% (64 vs. 43%, p = 0.03), and readmission rate (33 vs. 18%, p = 0.05). Whites had a higher prevalence of atrial fibrillation (42 vs. 21%, p = 0.006) and more frequently followed up with their cardiologists as outpatients (58 vs. 39%, p = 0.04). CONCLUSION: Significant racial differences exist in patients with heart failure with regard to age, incidence, etiologic factors, left ventricular hypertrophy, left ventricular function, and clinical follow-up. It is important to consider these racial differences in the evaluation and management of patients with heart failure.

Impact of pre-existing left ventricular dysfunction on kidney transplantation outcomes: implications for patient selection.

BACKGROUND: End-stage kidney disease patients with decreased left ventricular ejection fraction (EF) are often denied kidney transplantation (KT) for fear of poor graft and patient survival. METHODS: We retrospectively studied all patients who underwent KT at our center between 2001 and 2005 to determine the impact of low EF on outcomes post KT. Low EF was defined as <50% EF by noninvasive cardiac imaging. Follow-up was for 1 year post KT. Outcomes assessed included hospitalization for congestive heart failure (CHF), cardiac events, and renal allograft and patient survival. RESULTS: Among 254 patients, 37 had low EF (study group) and 217 had normal EF (≥50%; control group). Post KT, the low EF group had a significantly higher rate of hospitalization for CHF. No significant difference was noted in the rate of cardiac events, graft loss, GFR, and all cause death at 12 months post KT. CONCLUSION: Patients with low EF should not be excluded from transplantation, given favorable outcomes.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy: review for the clinician.

Although hypertrophic obstructive cardiomyopathy remains the most common cause of sudden cardiac death in young people, rarer causes, such as arrhythmogenic right ventricular dysplasia (ARVD), are now being increasingly recognized to lead to sudden cardiac death in the younger population. Recent advances in the understanding of the genetic inheritance, etiopathogenesis, diagnosis, and treatment options of ARVD have prompted a lot of research in this form of right ventricular cardiomyopathy. The purpose of this report is to review the etiopathogenesis, clinical manifestations, diagnosis and treatment modalities for ARVD, and recent advances in the understanding of this disease entity.

Heparin-induced thrombocytopenia and thrombosis.

Heparin remains the most commonly used parenteral medication in hospitalized patients. Heparin induced thrombocytopenia (HIT) and heparin induced thrombocytopenia with thrombosis syndrome or the white clot syndrome are important complications of heparin use. This article provides an in-depth review of the etiopathogenesis, clinical manifestations, diagnosis, and management options in patients with HIT. Clinical problems associated with HIT such as antiphospholipid antibody syndrome and venous gangrene are described. The management options of HIT patients during cardiac interventional procedures and coronary surgery as well as recent advances in therapeutic options are summarized.