Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics.

BACKGROUND: Heart valve clinics (HVC) have been introduced to manage patients with valvular heart disease within a multidisciplinary team. OBJECTIVE: To determine the outcome benefit of HVC approach compared with standard of care (SOC) for patients with moderate and asymptomatic severe aortic stenosis (mAS and asAS). METHODS: Single-centre, observational registry of patients with mAS and asAS with at least one cardiac ambulatory consultation at our Cardiovascular Centre. Based on the outpatient strategy, patients were divided into HVC group, if receiving at least one visit at HVC, and SOC group, if followed by routine cardiac consultations. RESULTS: 2129 patients with mAS and asAS were divided into those followed in HVC (n=251) versus SOC group (n=1878). The mean age was 76.5±12.4 years; 919 (43.2%) had asAS. During a follow-up of 4.8±1.8 years, 822 patients (38.6%) died, 307 (14.4%) were hospitalised for heart failure and 596 (28%) underwent aortic valve replacement (AVR). After propensity score matching, the number of consultations per year, exercise stress tests, brain natriuretic peptide (BNP) determinations and CTs were higher in the HVC cohort (p<0.05 for all). A shorter time between indication of AVR and less advanced New York Heart Association class was reported in the HVC cohort (p<0.001 and p=0.032). Compared with SOC, the HVC approach was associated with reduced all-cause mortality (HR=0.63, 95% CI 0.40 to 0.98, p=0.038) and cardiovascular death (p=0.030). At multivariable analysis, the HVC remained an independent predictor of all-cause mortality (HR=0.54, 95% CI 0.34 to 0.85, p=0.007). CONCLUSIONS: In patients with mAS and asAS, the HVC approach was associated with more efficient management and outcome benefit compared with SOC.

Performance of non-invasive myocardial work to predict the first hospitalization for de novo heart failure with preserved ejection fraction.

AIMS: Non-invasive myocardial work (MW) is a validated index of left ventricular (LV) systolic performance, incorporating afterload and myocardial metabolism. The role of MW in predicting the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF) is still unknown. We aim to investigate the diagnostic performance of MW to predict the first de novo HFpEF hospitalization in ambulatory individuals with preserved LV ejection fraction. METHODS AND RESULTS: Twenty-nine patients with transthoracic echocardiography performed at least 6 months before the first HFpEF hospitalization were compared with 29 matched controls. MW was derived as the area of pressure-strain loop using speckle-tracking and brachial artery blood pressure. Global work index, global constructive work, global wasted work (GWW), and global work efficiency (GWE) were collected. First HFpEF hospitalization and its combination with cardiovascular death [major adverse cardiovascular events (MACE)] and all-cause of death [major adverse events (MAE)] were assessed. At baseline, future HFpEF patients showed lower global work index, global constructive work, GWE, and higher GWW than controls (all P < 0.05). At admission vs. baseline, GWE significantly decreased, and GWW increased in the HFpEF group (P < 0.05), whereas no significant difference was observed in the controls over time. GWW, with a cut-off of 170 mmHg%, showed the largest area under the curve (AUC) to predict first HFpEF hospitalization [AUC = 0.80, 95% confidence interval (CI) 0.69-0.91, P < 0.001], MACE (AUC = 0.80, 95% CI 0.66-0.90, P < 0.001), and MAE (AUC = 0.79, 95% CI 0.62-0.88, P = 0.001). GWW > 170 mmHg% was associated with a 4-fold increase of MACE (HR = 4.5, 95% CI 1.59-13.12, P = 0.005) and a 3-fold higher risk of MAE (HR = 2.9, 95% CI 1.24-6.6, P = 0.014). CONCLUSIONS: In ambulatory patients with preserved LV ejection fraction and risk factors, GWW showed high accuracy to predict the first HFpEF hospitalization and its combination with mortality. The GWW routine assessment may be clinically helpful in patients with dyspnoea.

Importance of In-Hospital Prospective Registry and Infectious Endocarditis Heart Team to Monitor and Improve Quality of Care in Patients with Infectious Endocarditis.

AIM: To investigate the value of prospective in-hospital registry data and the impact of an infectious endocarditis heart team approach (IEHT) on improvement in quality of care and monitor outcomes in hospitalized patients with IE. METHODS: Between December 2014 and the end of 2019, 160 patients were hospitalized in one centre with the definite diagnosis of infectious endocarditis (IE) and entered in a prospective registry. From 2017, an IEHT was introduced. Propensity score matching was used to assess the impact of an IEHT approach on clinical outcomes. RESULTS: Median age was 72.5 y (62.75-80.00), diabetes was present in 33.1%, chronic kidney disease in 27.5%, COPD in 17.5%, and a history of ischaemic heart disease in 30.6%. Prosthetic valve IE was observed in 43.8% and device-related IE in 16.9% of patients. Staphylococcus (37.5%) was the most frequent pathogen followed by streptococcus (24.4%) and enterococcus (23.1%). Overall, 30-day and 1-year mortality were 19.4% and 37.5%, respectively. The introduction of prospective data collection and IE heart team was associated with a trend towards reduction of adjusted 1-year mortality (26.5% IEHT vs. 41.2% controls, p = 0.0699). An IEHT clinical decision-making approach was independently associated with a shorter length of stay (p = 0.04). CONCLUSIONS: Use of a prospective registry of IE coupled with a heart team approach was associated with more efficient patient management and a trend towards lower mortality. Prospective data collection and dedicated IEHT have the potential to improve patient care and clinical outcomes.

Acute Heart Failure as a First Presentation of Pheochromocytoma Complicated with "Inverted" Takotsubo Syndrome.

Takotsubo syndrome is a rare but emerging form of acute reversible myocardial injury characterized by transient systolic LV dysfunction, often related to emotional or physical stress. Pheochromocytoma is increasingly recognised as another possible trigger. Pheochromocytoma is a rare catecholamine-secreting tumour arising from chromaffin cells within the adrenal medulla or extra-adrenal paraganglia. The pathognomonic quartet of paroxysmal hypertension, palpitations, headache, and diaphoresis is rarely present, and diagnosis is often delayed. We describe a 43-year-old formerly healthy patient with an adrenal pheochromocytoma, presenting as an "inverted" takotsubo syndrome complicated with acute heart failure and pulmonary oedema.

Impact of non-invasive anatomical testing on optimal medical prescription in patients with suspected coronary artery disease.

BACKGROUND: Compared to functional testing, coronary computed tomography angiography (CTA) improves clinical outcomes in patients with suspected coronary artery disease (CAD). This is thought to be the result of an increased prescription of preventive medical therapy (statins and aspirin) when relying on a CTA imaging strategy. We compared the rate of statins prescription in a patient cohort assessed either with coronary CTA or exercise testing, and evaluated the agreement on medication prescriptions. METHODS: Consecutive patients who underwent coronary CTA and exercise test for suspected CAD were included. Four clinical cardiologists independently analysed each case based on clinical information and the result of either coronary CTA or exercise test. For each case, treatment strategy and prescription were recorded while blinded to the results of the other cardiac test. Treatment strategy was reassessed using the alternative imaging modality three weeks after the first evaluation. RESULTS: A total of 113 patients were included. Mean age was 56.7±11.5 years, 52% were males and diabetes were present in 6%. Coronary CTA showed an obstructive epicardial stenosis in 21.4% and any type of atherosclerotic plaque in 54.2%. Functional testing identified ischemia in 9.1%. The use of coronary CTA resulted in higher number of statin (64.9% vs. 44.5%, P<0.001) and aspirin (21.4% vs. 4.3%, P<0.001) prescriptions. There was a substantial agreement on the prescription of statins (mean Cohen's κ coefficient of 0.79±0.07). CONCLUSIONS: Epicardial atherosclerotic disease was found in half of patients with suspected CAD as assessed by coronary CTA. Compared to functional testing, coronary CTA evaluation by coronary was associated with an increase in the rate preventive therapy prescription.

A shocking bike accident.

CLINICAL INTRODUCTION: A man in his late 40s presented with severe chest pain and progressive dyspnoea after hitting a tree at high speed during a bike ride in the woods. On admission, the patient appeared agitated, pale and sweaty. Core temperature was 35.5°C, respiratory rate 35/min and blood pressure 90/50 mm Hg with a regular pulse at 110 beats/min. Physical examination revealed multiple sternal bruises, distended jugular veins and muffled heart sounds (figure 1A). Lactate level was 4.4 mmol/L (normal <2.0 mmol/L) and high-sensitivity cardiac troponin T 0.142 mcg/L (normal <0.005 mcg/L). An ECG and a total body CT scan were performed (figure 1B,C).heartjnl;104/20/1706/F1F1F1Figure 1(A) Multiple sternal bruises. (B) ECG on admission. (C) Thoracic CT. QUESTION  WHAT IS THE MOST LIKELY DIAGNOSIS?: Inferior myocardial infarction with right ventricular involvement.Cardiac contusion with tamponade.Commotio cordis.Aortic laceration.

Giant left circumflex coronary artery aneurysm with fistula to the right atrium.

Coronary artery fistulae are rare cardiac anomalies with a prevalence of 0.2% of all the patients undergoing coronary angiography. The majority of them are congenital and generally origin from the right coronary artery. Occasionally acquired (mostly iatrogenic) fistulae can develop. Although frequently subclinical, symptoms of angina and congestive heart failure may occur. We present an unusual well-illustrated case of a strongly dilated circumflex coronary artery with formation of two giant aneurysms and fistulous communication towards the right atrium.

An unexpected complication of chronic myelomonocytic leukemia: severe renal failure due to malignant tubulo-interstitial cell infiltration.

Acute renal failure may complicate the course of a hematologic malignancy but is a highly unusual finding in patients with chronic myelomonocytic leukemia. Kidney biopsy is rarely performed in this setting, and the pathologic substrate underlying kidney injury is not well identified. We present a case of a biopsy-proven acute tubulo-interstitial nephritis due to massive infiltration of neoplastic myelomonocytic cells. Since the leukemic process involving the kidney may respond favorably to treatment, a renal biopsy should be considered in any patient presenting with unexplained severe or evolving kidney disease.

Cerebral aspergillosis in adult critically ill patients: a descriptive report of 10 patients from the AspICU cohort.

An unexpectedly high incidence of invasive pulmonary aspergillosis (IPA) has been reported in non-neutropenic intensive care unit (ICU) patients. After the respiratory tract, the brain is most often affected by invasive aspergillosis. However, little is known about brain involvement by Aspergillus in critically ill patients. In this study, demographics, risk profile, diagnosis, treatment and outcome of proven cases of invasive cerebral aspergillosis (ICA) taken from a cohort of 563 adult patients with evidenced Aspergillus involvement during their ICU stay were reviewed. Ten patients with central nervous system aspergillosis were identified. All had one or more host factors predisposing for invasive aspergillosis. The clinical and radiological presentation was non-specific and exclusively pulmonary-related. All but one patient had proven or probable/putative IPA. On cerebral computed tomography, lesions appeared as either solitary and hyperdense or were multiple and randomly distributed throughout the brain. One patient presented with sole meningeal infestation. Aspergillus infection was confirmed by brain biopsy in three subjects. Voriconazole was used as primary treatment in only one-half of the patients. Mortality was 90%. ICA is not frequently observed in adult ICU patients. Diagnosis must be considered in patients at risk presenting with proven or probable/putative IPA in association with suggestive neuroradiological findings. The brain is most likely affected through haematogenous dissemination from the lungs. Current treatment recommendations are not always applied and outcome remains dismal.