The impact of the multidisciplinary Endocarditis Team on the management of infective endocarditis.

BACKGROUND: In their latest guidelines for infective endocarditis (IE) (2015), the European Society of Cardiology (ESC) introduced the implementation of the Endocarditis Team (ET) to facilitate the management of IE. This study presents our experiences and the diagnostic and therapeutic impact of the ET on the management of IE. METHODS: From 2016-2020, data of all patients with suspected IE referred to the ET were prospectively collected. The final diagnosis was defined by the ET as either rejected, possible or definite IE. Diagnostic impact was scored as any change in initial diagnosis, the frequency of additional diagnostic tests advised by the ET and any change in diagnosis after these tests. Therapeutic impact was scored as any change in antibiotic therapy or change from conservative to invasive therapy or vice versa. RESULTS: A total of 321 patients (median age 67 [55-77] years, 71% male) were enrolled. The final diagnosis was rejected IE in 47 (15%), possible IE in 34 (11%) and definite IE in 240 (75%) patients. A change of initial diagnosis was seen in 53/321(17%) patients. Additional microbiological tests were advised in 69/321 (21%) patients, and additional imaging tests in 136/321 (42%) patients, which resulted in subsequent change in diagnosis in 23/321 (7%) patients. Any change in antibiotic treatment was advised in 135/321 (42%) patients, and change from initial conservative to additional surgical treatment in 15/321 (5%) patients. CONCLUSION: The ET had a clear impact on the therapeutic policy for patients with suspected IE and is useful in the management of this life-threatening disease. Broad implementation is warranted.

Predictors of postoperative cardiovascular complications up to 3 months after kidney transplantation.

BACKGROUND: Renal transplant patients have a high peri-operative risk for cardiovascular events. Pre-operative screening for cardiac ischaemia might lower this risk, but there are no specific guidelines. METHODS: We conducted a chart review for all renal transplants performed between January 2010 and December 2013. We collected data about patient characteristics, pre-operative cardiac evaluation before referral, diagnostic tests and interventions. Logistic regression analyses were then applied to relate these factors to the composite endpoint of cardiac death, myocardial infarction, coronary revascularisation or admission for heart failure within 3 months after transplantation. RESULTS: A total of 770 kidney transplants were performed in 751 patients. In 750 cases (97%) a referral to the cardiologist was made. Non-invasive ischaemia detection by myocardial perfusion scintigraphy, exercise stress test or dobutamine stress echocardiography was carried out in 631 cases (82%). Coronary angiography was performed in 85 cases, which revealed significant coronary artery disease in 19 cases. Prophylactic revascularisation was done in 7 cases. The incidence of the study endpoint was 8.6%. In multivariable regression analysis, age at transplantation, pre-transplant myocardial infarction or heart failure, post-operative decrease in haemoglobin and positive non-invasive ischaemia testing were significantly associated with the study endpoint. However, when analysed separately, none of the different non-invasive ischaemia detection modalities were related to the study endpoint. CONCLUSION: Especially those renal transplant candidates with a cardiac history carry a high risk for a cardiovascular event post-transplantation. Uniformity in cardiac screening of renal transplant candidates and better pre-operative preparation might lower this post-operative risk. Besides, post-transplant anaemia should be prevented.

Association between cardiovascular disease and a history of cancer in patients with chest pain on the fast track outpatient clinic.

BACKGROUND: The purpose of this study is to investigate the prevalence of a history of malignancy in patients with chest pain who were referred for computed tomography angiography as well as the long-term survival and cardiovascular outcomes, including coronary artery disease (CAD) and coronary artery calcium (CAC) percentiles of cancer survivors. These data are relevant since it is unknown how cancer survivors, who underwent cardio-toxic therapies, should be monitored. METHODS: We analysed all patients with chest pain, who came to the outpatient clinic and underwent computed tomography angiography. The primary study endpoint was long-term survival. The secondary endpoints included CAD on computed tomography angiogram (CTA), CAC percentiles, suspected and confirmed malignancy on CTA, and other accidental findings on CTA. RESULTS: Of all 1,892 patients included in the analyses, 133 (7%) had a history of malignancy and 1,759 (93%) did not. Mortality rates were higher for the cancer survivors (6.5% vs 20.9% after ten years, p < 0.001). The multivariable Cox regression model also showed higher mortality for cancer survivors after ten years (adjusted hazard ratio 2.48 [95% confidence interval: 1.58-3.90]). CAD did not differ between both groups. CAC percentiles were higher in cancer survivors (p = 0.037). Cancer survivors had more suspected malignancies (3.8% vs 0.5%; p = 0.001) and also more confirmed malignancies on CTA (3.0% vs 0.1%; p < 0.001). CONCLUSIONS: Cancer survivors have higher mortality rates, no difference in CAD on CTA, higher CAC percentiles and more often malignancy on CTA compared with patients without a cancer history.

Peripheral arterial tonometry cannot detect patients at low risk of coronary artery disease.

BACKGROUND: Endothelial dysfunction precedes coronary artery disease (CAD) and can be measured by peripheral arterial tonometry (PAT). We examined the applicability of PAT to detect a low risk of CAD in a chest pain clinic. METHODS: In 93 patients, PAT was performed resulting in reactive hyperaemia (RHI) and augmentation (AIx) indices. Patients were risk classified according to HeartScore, Diamond and Forrester pretest probability (DF), exercise testing (X-ECG), and computed tomography calcium scoring (CCS) and angiography (CTA). Correlations, risk group differences and prediction of revascularisation within 1 year were calculated. RESULTS: RHI correlated with HeartScore (r = - 0.21, p = 0.05), AIx with DF (r = 0.26, p = 0.01). However, both were not significantly different between normal and ischaemic X-ECG groups. In addition RHI and AIx were similar between low risk as compared with intermediate-to-high risk, based on risk algorithms (RHI: 1.98 (0.67) vs 1.94 (0.78); AIx: 0.0 (21) vs 5.0 (25); p = NS), or CCS and CTA (RHI: 1.99 (0.58) vs 1.89 (0.82); AIx: - 2.0 (24) vs 4.0 (25); p = NS). Finally, RHI and AIx failed to predict revascularisation (RHI: OR 1.42, CI 0.65-3.1; AIx: OR 1.02, CI 0.98-1.05). CONCLUSIONS: PAT cannot detect a low risk of CAD, possibly because RHI and AIx versus X-ECG, CCS and CTA represent independent processes.

First-line evaluation of coronary artery disease with coronary calcium scanning or exercise electrocardiography.

BACKGROUND: Although conventional (CAG) and computed tomography angiography (CTA) are reliable diagnostic modalities for exclusion of obstructive coronary artery disease (CAD), they are costly and with considerable exposure to radiation and contrast media. We compared the accuracy of coronary calcium scanning (CCS) and exercise electrocardiography (X-ECG) as less expensive and non-invasive means to rule out obstructive CAD. METHODS: In a rapid-access chest pain clinic, 791 consecutive patients with stable chest pain were planned to undergo X-ECG and dual-source CTA with CCS. According to the Duke pre-test probability of CAD patients were classified as low (<30%), intermediate (30-70%) or high risk (>70%). Angiographic obstructive CAD (>50% stenosis by CAG or CTA) was found in 210/791 (27%) patients, CAG overruling any CTA results. RESULTS: Obstructive CAD was found in 12/281 (4%) patients with no coronary calcium and in 73/319 (23%) with a normal X-ECG (p<0.001). No coronary calcium was associated with a substantially lower likelihood ratio compared to X-ECG; 0.11, 0.13 and 0.13 vs. 0.93, 0.55 and 0.46 in the low, intermediate and high risk group. In low risk patients a negative calcium score reduced the likelihood of obstructive CAD to less than 5%, removing the need for further diagnostic work-up. CCS could be performed in 754/756 (100%) patients, while X-ECG was diagnostic in 448/756 (59%) patients (p<0.001). CONCLUSIONS: In real-world patients with stable chest pain CCS is a reliable initial test to rule out obstructive CAD and can be performed in virtually all patients.

Clinical course of patients diagnosed with severe aortic stenosis in the Rotterdam area: insights from the AVARIJN study.

OBJECTIVE: To prospectively evaluate the clinical course of patients with severe aortic stenosis (AS) and identify factors associated with treatment selection and patient outcome. METHODS: Patients diagnosed with severe AS in the Rotterdam area were included between June 2006 and May 2009. Patient characteristics, echocardiogram, brain natriuretic peptide (NT-proBNP), and treatment strategy were assessed at baseline, and after 6, 12, and 24 months. Endpoints were aortic valve replacement (AVR) / transcatheter aortic valve implantation (TAVI) and death. RESULTS: The study population comprised 191 patients, 132 were symptomatic and 59 asymptomatic at study entry. Two-year cumulative survival of symptomatic patients was 89.8 % (95 % CI 79.8-95.0 %) after AVR/TAVI and 72.6 % (95 % CI 59.7-82.0 %) with conservative treatment. Two-year cumulative survival of asymptomatic patients was 91.5 % (95 % CI 80.8-96.4 %). Two-year cumulative incidence of AVR/TAVI was 55.9 % (95 % CI 47.5-63.5 %) in symptomatic patients. Sixty-eight percent of asymptomatic patients developed symptoms, median time to symptoms was 13 months; AVR/TAVI cumulative incidence was 38.3 % (95 % CI 23.1-53.3 %). Elderly symptomatic patients with multiple comorbidities were more likely to receive conservative treatment. CONCLUSIONS: In contemporary Dutch practice many symptomatic patients do not receive invasive treatment of severe AS. Two-thirds of asymptomatic patients develop symptoms within 2 years, illustrating the progressive nature of severe AS. Treatment optimisation may be achieved through careful individualised assessment in a multidisciplinary setting.

Ultrasonographic and DSCT scan analysis of single lima versus arterial T grafts 12 years after surgery.

AIM: The aim of this study was to investigate long-term graft outcome in patients with left internal mammary artery to left anterior descending coronary artery (LIMA-LAD) and T-grafts by ultrasonography and dual source computed tomography (DSCT) and to analyse if ultrasonography can determine graft patency. METHODS: Thirty-two patients, 28 males, 50.8+/-8.8 years at operation, were studied. Fifteen patients with single LIMA-LAD and additional vein grafts (group I) and 17 patients with LIMA-free right internal mammary artery (FRIMA) T-grafts (group II) underwent DSCT, transthoracic ultrasonography of the LIMA and an electrocardiogram. Differences were tested with unpaired and paired t tests. RESULTS: In group I, 4.1+/-1.1 and in group II, 4.5+/-1.1 anastomoses/patients were performed. DSCT showed three string sign LIMA (20%) grafts and six occluded venous anastomoses (13%) in group I and three (distal) string sign LIMA grafts (18%), seven occluded LIMA anastomoses (23%) and nine occluded FRIMA anastomoses (23%) in group II. Ultrasonographic variables in the proximal part of the LIMA graft did not differ between the groups. No effect was found for proximal string sign LIMA grafts in ultrasonographic graft performance. CONCLUSION: Ultrasonography cannot distinguish between string sign and patent single LIMA or T-grafts nor demonstrate distal anastomosis patency in T-grafts 12 years after surgery.

Contrast echocardiography: mechanism of action, safety and clinical applications.

Since its initial description by Gramiak and Shah in 1968, contrast echocardiography has become an established practice world-wide. Microbubbles have the unique property of being pure intravascular tracers. The basic rationale behind bubble imaging is the characteristic responses to ultrasound power that results in enhanced ultrasound images from the blood pool. Therefore, whenever there is blood pool there is a potential application for contrast ultrasound. Clinical applications of contrast echocardiography have been vastly grown from diagnostic applications such as detection of a persistent foramen ovale to drug delivery. This article reviews the mechanism of action, safety and clinical applications of contrast echocardiography.

Computed tomography versus exercise electrocardiography in patients with stable chest complaints: real-world experiences from a fast-track chest pain clinic.

OBJECTIVE: To compare the diagnostic performance of CT angiography (CTA) and exercise electrocardiography (XECG) in a symptomatic population with a low-intermediate prevalence of coronary artery disease (CAD). DESIGN: Prospective registry. SETTING: Tertiary university hospital. PATIENTS: 471 consecutive ambulatory patients with stable chest pain complaints, mean (SD) age 56 (10), female 227 (48%), pre-test probability for significant CAD >5%. INTERVENTION: All patients were intended to undergo both 64-slice, dual-source CTA and an XECG. Clinically driven quantitative catheter angiography was performed in 98 patients. MAIN OUTCOME MEASURES: Feasibility and interpretability of, and association between, CTA and XECG, and their diagnostic performance with invasive coronary angiography as reference. RESULTS: CTA and XECG could not be performed in 16 (3.4%) vs 48 (10.2%, p<0.001), and produced non-diagnostic results in 3 (0.7%) vs 140 (33%, p<0.001). CTA showed > or =1 coronary stenosis (> or =50%) in 140 patients (30%), XECG was abnormal in 93 patients (33%). Results by CTA and XECG matched for 185 patients (68%, p = 0.63). Catheter angiography showed obstructive CAD in 57/98 patients (58%). Sensitivity, specificity, positive and negative predictive value of CTA to identify patients with > or =50% stenosis was 96%, 37%, 67% and 88%, respectively; compared with XECG: 71%, 76%, 80% and 66%, respectively. Quantitative CTA slightly overestimated diameter stenosis: 6 (21)% (R = 0.71), compared with QCA. Of the 312 patients (66%) with a negative CTA, 44 (14%) had a positive XECG, but only 2/17 who underwent catheter angiography had significant CAD. CONCLUSION: CTA is feasible and diagnostic in more patients than XECG. For interpretable studies, CTA has a higher sensitivity, but lower specificity for detection of CAD.

Clinical usefulness of SonoVue contrast echocardiography: the Thoraxcentre experience.

Although other imaging techniques, such as magnetic resonance imaging and computer tomography, are becoming more and more important in cardiology, two-dimensional echocardiography is still the most used technique in clinical cardiology. Quantification of left ventricular function and dimensions is important because therapeutic strategies, for example implanting an ICD after myocardial infarction, are based on ejection fraction measurements. Because of the sometimes low quality of echocardiographic images we started to use an ultrasound contrast agent and in this article we describe our experiences with SonoVue, a second-generation contrast agent, over a threeyear period in the Thoraxcentre. (Neth Heart J 2007;15:55-60.).

A patient with four artificial heart valves after ergotamine therapy.

A 67-year-old female was evaluated in the out-patient clinic because of shortness of breath on exertion and regular spells of fever. She had been taking ergotamine tartrate to treat migraine for more than 30 years. The patient had undergone aortic-valve replacement for aortic insufficiency three years before. On echocardiographic evaluation, severe retraction and insufficiency of the remaining native heart valves was demonstrated. Endocarditis and carcinoid syndrome were excluded. The mitral, tricuspid and pulmonary valves were all replaced by a mechanical valvular prosthesis. Pathological-anatomical evaluation of the three replaced valves and the aortic valve replaced three years earlier disclosed identical findings, compatible with long-term ergotamine use. Nine months after surgery, a sick sinus syndrome developed necessitating implantation of a DDDR pacemaker with a right atrial and a coronary sinus lead. Functional class according to the New York Heart Association improved from class III to I. After stopping the ergotamine, the fever disappeared. However, the migraine spells reoccurred which are now being treated with paracetamol.

Role of echocardiography in the diagnosis and management of infective endocarditis.

Infective endocarditis is one of the most common causes of serious infection and carries a high risk of morbidity and mortality. It represents the fourth leading cause of life-threatening infections after urosepsis, pneumonia, and intra-abdominal sepsis. There is still a continuous rise in the incidence of infective endocarditis, with a rate of about 20,000 new cases in the United States alone. This rise in incidence of infective endocarditis is mainly caused by increasing numbers of intravenous drug abusers, patients with artificial valves and elderly patients. In this paper, we will briefly review the crucial role of echocardiography in the diagnosis and management of infective endocarditis.

Usefulness of power Doppler contrast echocardiography to identify reperfusion after acute myocardial infarction.

Microvascular integrity, as seen by myocardial contrast echocardiography (MCE), assesses whether myocardium has been successfully reperfused after an acute myocardial infarction. Until now this has been demonstrated only with intracoronary injection of an ultrasound contrast agent. Power Doppler imaging is a recently developed myocardial contrast echocardiographic method that counts the contrast microbubbles destroyed by ultrasounds and displays this number in color. This study sought to evaluate whether power Doppler MCE is able to visualize myocardial reperfusion during intravenous contrast injection. Thirty patients were evaluated 2 days after their first myocardial infarction during intravenous infusion of perfluorocarbon-exposed sonicated dextrose albumin (PESDA). Coronary artery angiography and single-photon emission computed tomography (SPECT) were used as reference techniques. A 16-segment left ventricular model was used to relate perfusion to coronary artery territories. Sensitivity and specificity of power Doppler MCE for segments supplied by infarct-related arteries were 82% and 95%, respectively. Accuracy of power Doppler MCE and SPECT were similar (90% vs 92% on segmental basis and 98% vs 98% on coronary artery territory basis). Two-dimensional echocardiography was repeated after 6 weeks. Segments recovering wall motion after 6 weeks were defined as stunning myocardium. Dysfunctional but perfused myocardium at day 2 after the infarction showed a better late recovery of wall motion compared with dysfunctional but nonperfused myocardium (p <0.001). In conclusion, harmonic power Doppler imaging is a sensitive and specific method for the identification of myocardial reperfusion early after myocardial infarction. It yields prognostic information for late recovery of ventricular function differentiating stunning (dysfunctional but perfused) from necrotic myocardium (dysfunctional and nonperfused).

Effect of harmonic imaging without contrast on image quality of transesophageal echocardiography.

Harmonic imaging improves endocardial border delineation during transesophageal echocardiography when compared with conventional imaging (26% improvement vs 2% worsening; p <0.001). This allows better assessment of left ventricular function during cardiac surgery, and suggests a role of harmonic imaging for transesophageal echocardiography.

Effects of early intervention with low-dose aspirin (100 mg) on infarct size, reinfarction and mortality in anterior wall acute myocardial infarction.

Recently, it was shown that aspirin given early in acute myocardial infarction (AMI) improves hospital survival, but the mechanisms involved are unclear. In a prospective, randomized placebo-controlled trial, the influence of early intervention with low-dose aspirin (100 mg/day) on infarct size and clinical outcome was studied in 100 consecutive patients with first anterior wall AMI. Infarct size was calculated by cumulative lactate dehydrogenase release in the first 72 hours after admission and was found to be (mean +/- standard deviation) 1,431 +/- 782 U/liter in the aspirin group (n = 50) and 1,592 +/- 1,082 U/liter in the placebo group (n = 50, p = 0.35). The study medication was given for 3 months, during which mortality was 10 (20%) in the aspirin patients and 12 (24%) in the placebo patients (p = 0.65). However, reinfarction occurred in 2 patients (4%) in the aspirin group and in 9 (18%) in the placebo group (p less than 0.03). Early intervention with low-dose aspirin showed, in comparison to placebo, a 10% decrease of infarct size, but this difference was not statistically significant. However, early low-dose aspirin effectively decreased the risk of reinfarction. Therefore, the favor able results of early aspirin on mortality in acute myocardial infarction are probably due more to prevention of reinfarction than to decrease of infarct size.

Left ventricular thrombus incidence and behavior studied by serial two-dimensional echocardiography in acute anterior myocardial infarction: left ventricular wall motion, systemic embolism and oral anticoagulation.

Serial two-dimensional echocardiography was performed to detect left ventricular thrombus in 92 consecutive patients with a confirmed first acute anterior myocardial infarction. Thirty left ventricular thrombi were diagnosed in these 92 patients. The cumulative percent of identified thrombus in each echocardiographic examination in the surviving patients was 27% at less than 24 h; 57% at 48 to 72 h; 75% at 1 week and 96% at 2 weeks. The thrombus shape was defined as mural in 53% and protruding in 47% of patients. Systemic embolism (stroke) was noted during hospitalization in two patients with a protruding thrombus. At 12 weeks of follow-up, patients with thrombus had poorer (and almost unchanged from baseline) global left ventricular function as expressed by wall motion score compared with that of patients without thrombus, who exhibited significant improvement. Global left ventricular wall motion in patients with persisting or resolved thrombus was similar during follow-up. Apical wall motion worsened in 70% of the patients with persisting thrombus and in 25% of the patients with resolved thrombus (p less than 0.1). In the 22 surviving patients with thrombus, resolution or change in thrombus shape or size was noted in 14 of the 15 patients receiving anticoagulant therapy and in 4 of the 7 untreated patients. Six of the 18 patients with an early- (48 to 72 h) and none of the 12 patients with a later-formed thrombus died. Maximal serum enzyme levels, percent with Killip functional class III to IV and left ventricular wall motion score were higher in the patients with an early- than in those with a later-formed thrombus.(ABSTRACT TRUNCATED AT 250 WORDS)