The role of cardiac computed tomography in the diagnosis of prosthetic valve endocarditis - A comparison with transthoracic and transesophageal echocardiography and intra-operative findings.

BACKGROUND: Infective endocarditis is one of the most severe complications after prosthetic valve implantation and an accurate diagnosis is a clinical challenge. The purpose was to assess the diagnostic usefulness of cardiac computed tomography (CT) in valvular and perivalvular complications in patients with prosthetic valve endocarditis (PVE) and to compare CT results with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and intraoperative findings. METHODS: The retrospective study included 44 consecutive patients with PVE who underwent cardiac surgery. The mean age was 59.6 ±â€¯12.9 years, 33 (75 %) were males. The presence of vegetations, abscess/pseudoaneurysm, paravalvular leakage (PVL) and inflammatory infiltration were evaluated by TTE, TEE and CT prior to surgery and the results were compared with intraoperative findings. RESULTS: Endocarditis affected 47 valves (26 mechanical, 21 biological) in 44 patients. PVE most often affected the aortic valve (n = 36), followed by the mitral valve (n = 9) and the pulmonary valve (n = 2). In the per-valve analysis, the sensitivity of TTE, TEE and CT in diagnosing vegetations was 65 %, 91 % and 96 %; abscess 44 %, 77 % and 89 %; paravalvular leakage 90 %, 100 % and 70 %; inflammatory infiltration 39 %, 56 % and 78 %, respectively. The combination of CT and echocardiography allowed the detection of abscesses/pseudoaneurysms and inflammatory infiltration in all cases except one. CONCLUSION: CT was superior to echocardiography in the diagnosis of paravalvular abscesses, vegetations and inflammatory infiltration. Echocardiography had a higher diagnostic value to CT in the evaluation of paravalvular leakage. Cardiac CT combined with echocardiography improves the diagnostic accuracy of PVE and both modalities should be performed.

The usefulness of cardiac CT in the diagnosis of perivalvular complications in patients with infective endocarditis.

OBJECTIVES: The aim of the study was to compare the usefulness of cardiac CT to transthoracic (TTE) and transesophageal (TEE) echocardiography in the diagnosis of infective endocarditis (IE) and perivalvular complications using surgical inspection as the gold standard. MATERIAL AND METHODS: Fifty-three consecutive patients (42 men, mean age 58.3 ± 12.5) with IE requiring surgical procedures were enrolled in the study. All patients underwent preoperative TTE, TEE, and CT. The presence of vegetations, perivalvular abscess/pseudoaneurysm, leaflet perforation, inflammatory infiltration, and prosthesis dehiscence was assessed. RESULTS: We analyzed 71 affected valves (58 native, 13 prosthetic). Intraoperative assessment revealed 11 abscesses/pseudoaneurysms. Sensitivity and specificity of echocardiography (TTE + TEE) and CT were 63%, 90% and 81%, 90%, respectively. The combination of CT and echocardiography allowed diagnosing all abscesses/pseudoaneurysms. Inflammatory infiltration was found intraoperatively in 15 patients. Sensitivity and specificity of TEE and CT were 53%, 94% and 46%, 100%, respectively. Intraoperative assessment revealed leaflet perforation in 16 patients. Sensitivity and specificity of TEE and CT were 75%, 79% and 43%, 89%. The sensitivity of the combination of TTE + TEE + CT was 81%. Perivalvular leakage was found in eight patients with a prosthetic valve. Sensitivity and specificity of echocardiography and CT were 100%, 100% and 88%, 100%, respectively. TEE showed higher sensitivity (97%) than CT (89%) in the diagnosis of vegetations. CONCLUSIONS: The combination of TTE, TEE, and CT increased the sensitivity for the detection of valvular and perivalvular complications of IE. KEY POINTS: • CT is a useful modality in the diagnosis of IE and its local complications in addition to echocardiography. • For the detection of abscesses and pseudoaneurysms, CT is superior to echocardiography. Combining these two modalities can increase the sensitivity of diagnosing abscess/pseudoaneurysm up to 100%. • Adding CT to TEE increases the sensitivity for detection of inflammatory infiltrate. CT is not superior to echocardiography in diagnosing vegetations, valvular leaflet perforations, and perivalvular leaks, but it can be a useful tool when echocardiography is indeterminate.

Functional polymorphism of the renalase gene is associated with cardiac hypertrophy in female patients with aortic stenosis.

Renalase decreases circulating catecholamines concentration and is important in maintaining primary cellular metabolism. Renalase acts through the plasma membrane calcium ATPase 4b in the heart, which affects pressure overload but not exercise induced heart hypertrophy. The aim of this study was to test the association between a functional polymorphism Glu37Asp (rs2296545) of the renalase gene and left ventricular hypertrophy in a large cohort of patients with aortic stenosis. The study group consisted of 657 patients with aortic stenosis referred for aortic valve replacement. Preoperative echocardiographic assessment was performed to obtain cardiac phenotypes. Generalized-linear models were implemented to analyze data using crude or full model adjusted for selected clinical factors. In females, the Asp37 variant of the Glu37Asp polymorphism was associated with higher left ventricular mass (p = 0.0021 and p = 0.055 crude and full model respectively), intraventricular septal thickness (p = 0.0003 and p = 0.0143) and posterior wall thickness (p = 0.0005 and p = 0.0219) all indexed to body surface area, as well as relative wall thickness (p = 0.001 and p = 0.0097). No significant associations were found among the male patients. In conclusion, we have found the association of the renalase Glu37Asp polymorphism with left ventricle hypertrophy in large group of females with aortic stenosis. The Glu37Asp polymorphism causes not only amino-acid substitution in FAD binding domain but may also change binding affinity of the hypoxia- and hypertrophy-related transcription factors and influence renalase gene expression. Our data suggest that renalase might play a role in hypertrophic response to pressure overload, but the exact mechanism requires further investigation.

The impact of transcatheter aortic valve implantation on left ventricular performance and wall thickness - single-centre experience.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is a treatment alternative for the elderly population with severe symptomatic aortic stenosis (AS) at high risk for surgical aortic valve replacement (SAVR). AIM: To assess the impact of TAVI on echocardiographic parameters of left ventricular (LV) performance and wall thickness in patients subjected to the procedure in a single-centre between 2009 and 2013. MATERIAL AND METHODS: The initial group consisted of 170 consecutive patients with severe AS unsuitable for SAVR. Logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 21.73 ±12.42% and mean age was 79.9 ±7.5 years. RESULTS: The TAVI was performed in 167 (98.2%) patients. Mean aortic gradient decreased significantly more rapidly after the procedure (from 58.6 ±16.7 mm Hg to 11.9 ±4.9 mm Hg, p < 0.001). The LV ejection fraction (LVEF) significantly increased in both short-term and long-term follow-up (57 ±14% vs. 59 ±13%, p < 0.001 and 56 ±14% vs. 60 ±12%, p < 0.001, respectively). Significant regression of interventricular septum diameter at end-diastole (IVSDD) and end-diastolic posterior wall thickness (EDPWth) was noted in early (15.0 ±2.4 mm vs. 14.5 ±2.3 mm, p < 0.001 and 12.7 ±2.1 mm vs. 12.4 ±1.9 mm, p < 0.028, respectively) and late post-TAVI period (15.1 ±2.5 mm to 14.3 ±2.5 mm, p < 0.001 and 12.8 ±2.0 mm to 12.4 ±1.9 mm, p < 0.007, respectively). Significant paravalvular leak (PL) was noted in 21 (13.1%) patients immediately after TAVI and in 13 (9.6%) patients in follow-up (p < 0.001). Moderate or severe mitral regurgitation (msMR) was seen in 24 (14.9%) patients from the initial group and in 19 (11.8%) patients after TAVI (p < 0.001). CONCLUSIONS: The TAVI had an immediate beneficial effect on LVEF, LV walls thickness, and the incidence of msMR. The results of the procedure are comparable with those described in other centres.

Factors affecting long-term survival after aortic valve replacement.

BACKGROUND AND AIM: To evaluate long-term outcomes of surgical aortic valve replacement (AVR) due to significant aortic stenosis (AS) and assess changes in factors affecting survival during a 10-year period in patients referred for surgery from a single centre. METHODS: We evaluated 1143 patients (478 women, 665 men; mean age 61 ± 5 years) treated in the Department of Valvular Heart Disease at the Institute of Cardiology in Warsaw who were referred for AVR due to significant AS in 1998-2008 and survived the surgery and the initial 30-day postoperative period. We assessed long-term survival in relation to preoperative parameters including demographic data (age, gender), clinical variables (New York Heart Association [NYHA] class, presence of a significant coronary artery stenosis, arterial hypertension, reduced left ventricular ejection fraction [LVEF]), and operative parameters (prosthetic valve type: biological vs. mechanical, and the type of the surgery: isolated AVR vs. AVR combined with coronary artery bypass grafting). RESULTS: Ten-year survival was worse in men compared to women (p = 0.001), with the effect of gender gradually decreasing after 3 years of follow-up. Factors affecting long-term survival included age (p = 0.0001) and NYHA class (p = 0.005) in women, and age (p = 0.0001), NYHA class (p = 0.0001), arterial hypertension (p = 0.01), reduced LVEF (p = 0.03), and the presence of significant coronary artery stenoses (p = 0.0001) in men. Evaluation of factors affecting 1-, 3-, 5-, and 7-year survival showed their variability mostly in men. CONCLUSIONS: Long-term surgical outcomes in patients with significant AS are very good, with better survival in women compared to men, although these differences attenuated after 3 years. Factors affecting 10-year survival are different in women and men: a significant effect in women was noted only for age and preoperative NYHA class, while in men for age, NYHA class, hypertension, reduced LVEF, and the presence of significant coronary artery stenoses. During 10-year follow-up, longitudinal changes can be noted in factors affecting survival after AVR.

[Early asymptomatic pacemaker lead thrombosis successfully treated with pharmacotherapy]. / Wczesna, bezobjawowa zakrzepicaelektrody ukladu stymulujacegoskutecznie leczona zachowawczo.

The case of a 85-year-old female with multiple prothrombotic risk factors, who developed asymptomatic lead thrombosis 36 h after pacemaker implantation is presented. The successful medical treatment with enoxaparin and oral anticoagulant was introduced.

Elevation of pulmonary artery pressure as a complication of nilotinib therapy for chronic myeloid leukemia.

We present the case of a 72-year-old male with chronic phase myeloid leukemia. Elevation of the pulmonary artery pressure due to nilotinib therapy was noted. This effect on pulmonary artery pressure was nilotinib dose dependent.

Inflammatory response and postoperative kidney failure in patients with diabetes type 2 or impaired glucose tolerance undergoing heart valve surgery.

BACKGROUND: Diabetes type 2 (DM) or impaired glucose tolerance (IGT) are linked with a 3-fold increased risk of renal failure after heart valve surgery. The increase of proinflammatory cytokines is detected in patients with DM or IGT, moreover cardiac surgery promotes the proinflammatory response, which may be responsible for the development of postoperative kidney failure. AIM: To assess the impact of perioperative pro- and antiinflammatory reaction after heart valve surgery and other clinical parameters on the risk of postoperative acute kidney injury in patients with DM or IGT. METHODS: Thirty patients with DM or IGT, without fibrate or statin treatment, with a mean LDL-cholesterol below 129 mg/dL, ejection fraction > 45%, in NYHA class II and III, referred for surgery due to acquired heart valve disease entered the study. Patients with acute or chronic inflammatory conditions, coronary artery disease or creatinine clearance below 50 mL/min were excluded. Serum creatinine, glycosylated hemoglobin, LDL-cholesterol and interleukin-10 as well as TNF-alpha were assessed before surgery. Interleukin-10 and TNF-alpha were also measured 4 hours after weaning from cardiopulmonary bypass. Moreover, serum creatinine and hemoglobin were measured 18 +/- 2 hours after surgery. The relationship between postoperative creatinine clearance, its postoperative change and other parameters was assessed. These parameters included: age, weight and body mass index, pre- and postoperative serum level of TNF-alpha and interleukin-10, preoperative concentration of LDL-cholesterol and glycosylated hemoglobin, duration of cardiopulmonary bypass and postoperative hemoglobin. RESULTS: The significant postoperative decrease of creatinine clearance was noted in the study group. Eight (27%) patients developed postoperative kidney failure, of them 2 (6.5%) patients required hemodialysis. The level of TNF-alpha and interleukin-10 increased significantly postoperatively. A significant correlation between duration of cardiopulmonary bypass and postoperative decrease of creatinine clearance was noted (R = 0.43, p = 0.02). A non-significant trend towards correlation between preoperative TNF-alpha and postoperative decrease of creatinine clearance was observed (R = -0.36, p = 0.05). CONCLUSIONS: Postoperative kidney failure with the incidence of 27% is a frequent finding in patients with DM or IGT operated due to acquired heart valve disease. The postoperative proinflammatory response is not involved in the development of this complication. The correlation between postoperative decrease of creatinine clearance and duration of cardiopulmonary bypass was noted. The trend toward the link between postoperative kidney failure and preoperative proinflammatory status was seen.

Early and long-term outcomes after surgical treatment in patients with aortic stenosis and severe left ventricular heart failure without concomitant coronary artery disease with respect to preoperative mean transvalvular pressure gradient.

INTRODUCTION: There are limited data on early and long-term prognosis in patients after aortic valve replacement who have left ventricular dysfunction, reduced ejection fraction (EF) < or =35% and no concomitant coronary artery disease. AIM: To assess the prognosis in this group of patients depending on the mean aortic gradient (MAG) value. METHODS: This study involved 60 patients with severe aortic stenosis and EF < or =35%. Patients with coronary artery disease, more than moderate aortic regurgitation and any other valvular lesion were excluded. Patients were divided into two groups based on the MAG values: group I included patients with MAG < or =35 mmHg, and group II included patients with MAG >35 mmHg. RESULTS: Early mortality after aortic valve replacement was 14.2% in group I, and 5.1% in group II. During a mean follow-up of 48 months mortality in groups I and II was 16.6% and 2.6%, respectively. In the follow-up period, a significant functional improvement according to NYHA scale as well as significant decrease of left ventricular dimensions and increase of EF was observed in both groups of patients. CONCLUSIONS: Patients with severe aortic stenosis, left ventricular ejection fraction <35% and MAG < or =35 mmHg constitute a group of the highest early and long-term mortality risk after valve replacement. In turn, patients with MAG >35 mmHg should be classified as the group of slightly increased risk.

[Plethysmographic assessment of pulse wave may be helpful in the detection of prosthetic valve dysfunction--a case report]. / Krzywa pletyzmograficzna moze byc pomocna w rozpoznawaniu dysfunkcji wszczepionej zastawki.

A case of a 63-year-old female with prosthetic mitral and aortic valves is described. The long-term post-operative period was complicated by infective endocarditis, persistent atrial fibrillation requiring pacemaker implantation and total a-v node ablation as well as ischaemic stroke which occurred one year before present hospitalisation. This time the patient was admitted to the hospital due to progressive heart failure. Transesophageal echocardiography showed a cyclic intermittent opening of both prosthetic valves full opening was present during every second cardiac cycle. The same phenomenon was documented using plethysmographic recording of a pulse wave from a finger. The patient underwent prosthetic valve replacement. Intraoperatively, a fibrous tissue ingrowth was detected.

Influence of ACE I/D genotypes on left ventricular hypertrophy in aortic stenosis: gender-related differences.

BACKGROUND AND AIM OF THE STUDY: Factors responsible for cardiac hypertrophy in patients with aortic stenosis (AS) are not well defined. The study aim was to examine the relationship between angiotensin-converting enzyme (ACE) I/D polymorphism and the degree of cardiac hypertrophy in patients with AS. METHODS: A total of 392 white patients (159 women, 233 men; age range: 32-82 years) with AS was analyzed, with clinical data, echocardiographic parameters and ACE I/D polymorphism being assessed. RESULTS: Left ventricular mass index (LVMI) and wall thickness (LVWT) were greater in men than in women (226 +/- 66 versus 200 +/- 68 g/m2, p <0.0001; and 28.4 +/- 4.5 versus 27.3 +/- 4.1 mm, p = 0.02, respectively). In all patients, LVMI was significantly correlated with the maximal aortic gradient, ejection fraction and gender, whereas LVWT was dependent upon maximal aortic gradient, ejection fraction, gender and history of hypertension. In women, cardiac hypertrophy increased with age. Hypertrophy in women aged <66 years correlated with an absence of the DD genotype. In men, a reverse correlation of both LVMI and LVWT with age was observed (higher in younger patients). The presence of a DD genotype in men seemed to have a significant impact on the degree of cardiac hypertrophy. CONCLUSION: The degree of left ventricular hypertrophy in patients with AS was higher in men than in women. ACE I/D polymorphism appeared to have a modulating impact on cardiac hypertrophy in patients with AS, notably those aged <66 years. A higher degree of cardiac hypertrophy was seen in men with the DD genotype, and in women without the DD genotype.

QT interval dispersion analysis in patients with aortic valve stenosis: a prospective study.

BACKGROUND AND AIM OF THE STUDY: QT interval dispersion (QTd) was analyzed in patients with aortic valve stenosis, and the relationship investigated between QTd, age, gender, hypertension, presence of significant coronary artery stenosis and left ventricular (LV) hypertrophy assessed by echocardiography. Results were also compared between survivors and patients who had cardiac arrest or died before, during or soon after cardiac surgery. METHODS: The group comprised 535 consecutive patients (217 women, 318 men; mean age 59 +/- 11 years; range: 20-81 years) with significant aortic valve stenosis before valve replacement. The control group comprised 35 healthy subjects (12 women, 23 men; mean age 51 +/- 11 years; range: 28-74 years). RESULTS: Mean QTd was 29 +/- 10 ms in controls and 59 +/- 24 ms in patients (p < 0.001). Gender had no impact on QTd. QTd was increased in men with significant coronary artery stenosis, and independently related strongly with ECG parameters (QTmax, heart rate) and weakly with age and degree of LV hypertrophy. In patients with cardiac arrest or those who died (n = 14), QTd was increased compared to that in survivors (71 +/- 22 versus 59 +/- 24 ms; p = 0.05), and QTd >70 ms was observed more frequently (p = 0.02; odds ratio 3.4, 1.16-10.0). CONCLUSION: QTd is abnormally increased in two-thirds of patients with aortic valve stenosis, and is increased in men with concomitant coronary artery disease. QTd >70 ms significantly increased the risk of cardiac arrest or death perioperatively. QTd was only weakly related with age and degree of LV hypertrophy, but QTmax and heart rate had a greater impact. QT dispersion analysis has limited clinical value in patients with aortic stenosis.

[Is there any difference in quality of life after 12 months surgical treatment of acquired heart valve disease in comparison to results after three months?]. / Czy istnieje róznica w jakosci zycia po 12 miesiacach od operacji nabytych wad zastawkowych w porównaniu z wynikami uzyskanymi po 3 miesiacach?

The quality of life in eighty patients three and twelve months after surgical treatment of acquired heart valve disease was assessed. The significant extension of distance in 6 minute walk test and clinical improvement measured in change of NYHA functional classes after three and twelve months was noticed. However twelve months after valve replacement in comparison to results after three months no further improvement of quality of life in the matter of physical, psychical and social factors was seen.

[The evaluation of the left ventricle function in patients with aortic stenosis and severe heart failure after surgical treatment of valvular heart disease]. / Ocena funkcji lewej komory u chorych ze zwezeniem zastawki aortalnej w okresie skrajnej niewydolnosci serca po leczeniu operacyjnym wady zastawkowej.

Surgical treatment of aortic stenosis in patients (pts) with severe heart failure represents high-risk procedure. The aim of this study was to identify prognostic factors and assess the late outcome after aortic valve replacement (AVR) in patients with isolated aortic stenosis and left ventricle ejection fraction (EF) < or = 40%. The study group consisted of 37 pts 25 (67%) men and 12 (33%) women, aged 57 +/- 12 yrs. Mean follow-up period was 18 +/- 17 months (range 6 to 72 months). Before AVR and within follow-up period clinical assessment was based on NYHA classes and echocardiographic study to evaluate left ventricle function. Early mortality rate was 8.3%, late mortality was 5.8%. EF significantly improved from 27 +/- 7% to 59 +/- 15% (p < 0.001) after AVR. It was accompanied by clinical improvement. Left ventricle function improvement did not depend on age, sex of patients, concomitant revascularization and preoperative maximum transaortic gradient. Significant correlation (r = -0.4, p = 0.02) between preoperative left ventricle end-diastolic diameter and postoperative EF improvement was noted.

[Influence of insertion-deletion polymorphism of the angiotensin converting enzyme gene on left ventricular hypertrophy in patients with aortic stenosis--differences in men and women]. / Polimorfizm insercyjno-delecyjny genu enzymu konwertujacego angiotensyne ma odmienny wplyw na wielkosc przerostu lewej komory u kobiet i mezczyzn ze zwezeniem zastawki aortalnej.

UNLABELLED: The role of different parameters (including genetic factors) on the timing and extend of left ventricle hypertrophy in patients with aortic stenosis is not defined. In our study we analyze the influence of clinical, echocardiographic parameters and I/D polymorphism of the angiotensin converting enzyme gene on the left ventricle hypertrophy (left ventricle mass index) in this group of patients. The study was done with the group of 302 pts with aortic stenosis--120 women and 182 men; mean age 58 +/- 11 yrs. Stepwise (backward) regression was used to assess the influence of the analyzed parameters (age, gender, history of hypertension, EF, MGA, presence of significant coronary artery disease and I/D ACE polymorphism) on the LVH in the all pts and in the women and the men separately. In the whole group the LVMI depends on EF (t = -6.5; p = 0.0001--higher LVMI in lower EF), MGA (t = 3.9; p = 0.0001--higher LVMI in higher MGA) and gender (t = 2.8; p = 0.005--higher LVMI in men). In women LVMI was related with EF (t = -3.6; p = 0.001--higher LVMI in lower EF), age (t = 2.9; p = 0.004--higher LVMI in older pts) and MGA (t = 2.5; p = 0.013--higher LVMI in higher MGA). In men the LVMI depends on EF (t = -4.8; p = 0.0001--higher LVMI in lower EF) and MGA (t = 1.98; p = 0.049--higher LVMI in higher MGA). Significant relationship between LVMI and results of I/D ACE polymorphism was observed both in women and men. I/D polymorphism relationship with LVMI was divergent in these 2 groups--association of higher LVMI with lack of DD type of polymorphism in women and presence of DD polymorphism in men. CONCLUSIONS: 1. Left ventricle hypertrophy in pts aortic stenosis is higher in men than in women. 2. In women left ventricle hypertrophy is related with ejection fraction, maximal aortic gradient, age and I/D ACE polymorphism; in men it is related to EF, MGA and I/D ACE polymorphism. 3. The influence of I/D ACE polymorphism on the left ventricle hypertrophy is divergent in women and men--in women related to the lack of DD polymorphism, in men related to the presence of DD polymorphism.