Comparison of Medical Therapy, Valve Surgery, and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis.

BACKGROUND: The opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided infective endocarditis are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients at high risk for re-infection of a prosthetic valve but lacks robust outcomes data. This retrospective analysis compares the primary outcome of death within 1 year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy alone vs percutaneous mechanical aspiration or valve surgery. METHODS: The authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic-and outcomes-related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting. RESULTS: Between January 1, 2009, and December 31, 2018, 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the 3 treatment groups (P = .15). Vegetation size > 2.0 cm was associated with increased 1-year mortality (hazard ratio 3.01; P = .03). Addiction medicine consultation was associated with decreased 1-year mortality (hazard ratio 0.117; P = .0008). CONCLUSION: The study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated tricuspid valve infective endocarditis. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.

Bedside ultrasound of the internal jugular vein to assess fluid status and right ventricular function: The POCUS-JVD study.

BACKGROUND: Accurate estimation of fluid status is important in the management of heart failure patients, however, the current methods for bedside assessment can be unreliable or impractical for daily use. METHODS: Non-ventilated patients were enrolled immediately prior to scheduled right heart catheterization (RHC). Using M-mode, IJV maximum (Dmax) and minimum (Dmin) anteroposterior diameters were measured during normal breathing, while supine. Respiratory variation in diameter (RVD) was calculated as [(Dmax - Dmin)/Dmax] in percentage. Collapsibility with sniff maneuver (COS) was assessed. Lastly, inferior vena cava (IVC) was assessed. Pulmonary artery pulsatility index (PAPi) was calculated. Data was obtained by five investigators. RESULTS: Total 176 patients were enrolled. Mean BMI was 30.5 kg/m2, LVEF 14-69% (range), 38% with LVEF ≤35%. The POCUS of IJV could be performed in all patients in <5 min. Increasing RAP demonstrated progressive increase in IJV and IVC diameters. For high filling pressure (RAP ≥10 mmHg), an IJV Dmax ≥1.2 cm or IJV-RVD < 30% had specificity >70%. Combining the POCUS of IJV to physical examination improved the combined specificity to 97% for RAP ≥10 mmHg. Conversely, a finding of IJV-COS was 88% specific for normal RAP (<10 mmHg). An IJV-RVD <15% is suggested as a cutoff for RAP ≥15 mmHg. The performance of IJV POCUS was comparable to IVC. For RV function assessment, IJV-RVD < 30% had 76% sensitivity and 73% specificity for PAPi <3, while IJV-COS was 80% specific for PAPi ≥3. CONCLUSION: POCUS of IJV is an easy to perform, specific and reliable method for volume status estimation in daily practice. An IJV-RVD < 30% is suggested for estimation of RAP ≥10 mmHg and PAPi <3.

Prevalence of Right- and Left-Sided Endocarditis Among Intravenous Drug Use Patients at a Large Academic Medical Center.

Background: Left-sided infective endocarditis (IE) is increasingly being recognized among intravenous drug use (IVDU) patients. We sought to assess the trends and risk factors that contribute to left-sided IE in this high-risk population at University of Kentucky. Methods: A retrospective chart review of patients with the diagnosis of both IE and IVDU admitted at University of Kentucky was carried out from January 1, 2015 to December 31, 2019. Baseline characteristics, trends of endocarditis and clinical outcomes (mortality and in-hospital interventions) were recorded. Results: A total of 197 patients were admitted for management of endocarditis. One hundred and fourteen (57.9%) had right-sided endocarditis, 25 (12.7%) had combined left-sided and right-sided endocarditis, and 58 (29.4%) had left-sided endocarditis. Staphylococcus aureus was the most common pathogen. Mortality and inpatient surgical interventions were higher among patients with left-sided endocarditis. Patent foramen ovale (PFO) was the most common shunt found (3.1%), followed by atrial septal defect (ASD, 2.4%) with PFO being significantly more common among patients with left-sided endocarditis. Conclusion: Right-sided endocarditis continues to be predominant among IVDU patients and Staphylococcus aureus was the most common organism involved. Patients with evidence of left-sided disease were found to have significantly more PFO, needed more inpatient valvular surgeries, and had higher all-cause mortality. Further studies are needed to assess if PFO or ASD can increase the risk of acquiring left-sided endocarditis in IVDU.

Sex and race define the effects of adverse childhood experiences on self-reported BMI and metabolic health biomarkers.

BACKGROUND: Adverse childhood experiences (ACEs) are an independent risk factor for chronic diseases, including type 2 diabetes, stroke and ischemic heart disease. However, the effect of ACEs considering sex and race are not often reported in cohorts showing multiracial composition, with power to evaluate effects on underrepresented populations. AIM: To determine how sex and race affected the association of combined and individual ACEs with metabolic health biomarkers in the Southern Community Cohort Study (2012-2015). METHODS: Self-reported data were analyzed from ACE surveys performed during the second follow-up of a cohort comprised by over 60% of Black subjects and with an overall mean age of 60 years. RESULTS: BMI steadily increased with cumulative ACEs among Black and White women, but remained relatively stable in White men with ≥ 4 ACEs. Contrary, Black men showed an inverse association between ACE and BMI. Secondary analysis of metabolic outcomes showed that physical abuse was correlated with a 4.85 cm increase in waist circumference in Black subjects. Total cholesterol increased among individuals with more than 4 ACEs. In addition, increases in HbA1c were associated with emotional and maternal abuse in Black women and sexual abuse in White women. CONCLUSIONS: BMI is strongly associated with cumulative ACEs in women regardless the race, while waist circumference is strongly associated with ACEs in Black individuals, which combined with reduced BMI may indicate increased central adiposity in Black men. Our study suggests that sex and race influence the contribution of certain ACEs to impair metabolic health.