Meta-analysis assessing the sensitivity and specificity of 18F-FDG PET/CT for the diagnosis of prosthetic valve endocarditis (PVE) using individual patient data (IPD).

IMPORTANCE: The use of 18F-FDG PET/CT in diagnostic algorithms for PVE has increased since publication of studies and guidelines advocating its use. The assessment of test accuracy has been limited by small study sizes. We undertook a systematic review using individual patient data (IPD) meta-analysis techniques. OBJECTIVE: To estimate the summary sensitivity and specificity of 18F-FDG PET/CT in diagnosing PVE. We also assessed the effect of patient factors on test accuracy as defined by changes in the odds ratios associated with each factor. The effect of the PET/CT study on the final diagnosis was also assessed when compared to the preliminary Duke classification to determine in which patient group 18F-FDG PET/CT had the greatest utility. STUDY SELECTION: Studies were included if PET/CT was performed for suspicion of PVE and IPD of both the PET/CT result and final diagnosis defined by a gold-standard assessment was available. There were 3 possible final diagnoses ("definite PVE," "possible PVE," and "rejected PVE"). RESULTS: Seventeen studies were included with IPD available for 537 patients (from 538 scans). The summary sensitivity and specificity were 85% (95% CI 74.2%-91.8%) and 86.5% (95% CI 75.8%-92.9%) respectively when patients with final diagnosis of "possible PVE" were classified as positive for PVE. When this group was classified as negative for PVE, sensitivity was 87.4% (95% CI 80.4%-92.1%) and specificity was 84.9% (95% CI 71.5%-92.6%). Patients with a known pathogen (especially coagulase negative staphylococcal species), elevated CRP, a biological or aortic valve infection appeared more likely to have an accurate PET/CT diagnosis. Those with a mechanical valve, prior antibiotic treatment or a transcatheter aortic valve replacement valve were less likely to have an accurate test. Time since valve implantation and the presence of surgical adhesive did not appear to affect test accuracy. Of the patients with a preliminary Duke classification of "possible PVE," 84% received a more conclusive final diagnosis of "definite" or "rejected" PVE after the PET/CT study. CONCLUSIONS AND RELEVANCE: 18F-FDG PET/CT has high sensitivity and specificity in diagnosing PVE and the diagnostic utility is greatest in patients with a preliminary Duke classification of "possible PVE." Some patient factors appear to affect test accuracy, though these results should be interpreted with caution given low patient numbers for subgroup analyses.

Managing blunt cardiac injury.

Blunt cardiac injury (BCI) encompasses a spectrum of pathologies ranging from clinically silent, transient arrhythmias to deadly cardiac wall rupture. Of diagnosed BCIs, cardiac contusion is most common. Suggestive symptoms may be unrelated to BCI, while some injuries may be clinically asymptomatic. Cardiac rupture is the most devastating complication of BCI. Most patients who sustain rupture of a heart chamber do not reach the emergency department alive. The incidence of BCI following blunt thoracic trauma remains variable and no gold standard exists to either diagnose cardiac injury or provide management. Diagnostic tests should be limited to identifying those patients who are at risk of developing cardiac complications as a result of cardiac in jury. Therapeutic interventions should be directed to treat the complications of cardiac injury. Prompt, appropriate and well-orchestrated surgical treatment is invaluable in the management of the unstable patients.

Temporary biventricular mechanical circulatory support utilizing a simple left ventricular apical cannulation technique.

Surgical management of cardiogenic shock, utilizing mechanical circulatory support, can provide a bridge to recovery, a bridge to decision-making, and/or a bridge to transplantation. The management of advanced heart failure, employing either temporary or durable mechanical circulatory support, dominantly is directed towards supporting the left ventricular (LV) function. Unfortunately, right ventricular (RV) failure is not uncommon and significantly impacts morbidity and mortality. We demonstrate a technique to support biventricular failure, utilizing a simple LV apical cannulation technique, which may reduce thrombotic complications, and an RV cannulation strategy that offers the potential to improve recovery, in the form of early extubation, potential ambulation, and removal of the implanted device without having to reopen the patient's chest.

Simple left ventricular apical cannulation for temporary mechanical circulatory support.

Surgical management of cardiogenic shock, utilizing mechanical circulatory support, can provide a bridge to recovery, bridge to decision making and/or bridge to transplantation. Despite extracorporeal membrane oxygenation (ECMO) being a reliable, temporary form of support, intracardiac thrombosis is a devastating complication of veno-arterial ECMO. The use of a temporary left ventricular assist device (LVAD), although not immune to thrombosis, helps reduce intracardiac thrombosis, maintaining flow through the heart but importantly allowing for concurrent venting and drainage of the left ventricle. We demonstrate a technique for LV apical cannulation, as a part of a temporary LVAD circuit, aiming to prevent thrombotic complications secondary to cannula angulation.

Unexpected giant cell aortitis in a young patient.

INTRODUCTION AND IMPORTANCE: Giant cell aortitis is a rare cause of ascending aortic aneurysm disease. Patients presenting with aneurysms caused by giant cell aortitis are at high risk of devastating complications. CASE PRESENTATION: A 35-year-old female with an ascending aortic aneurysm, underwent an aortic root and ascending aorta replacement and subsequently was found to have giant cell aortitis on histopathology. DISCUSSION AND CONCLUSION: This case illustrates a very rare cause for aortopathy in a young healthy patient, who may have ruptured or dissected, if not for timely operative intervention.

Intrapericardial bronchogenic duplication cyst.

Bronchogenic cysts arise from an abnormal budding of the ventral diverticulum of the foregut or the tracheobronchial tree, during embryogenesis. Intrapericardial cysts are rare, accounting for 27% of bronchogenic cysts. In this case report, we present a young woman with a symptomatic intrapericardial bronchogenic cyst compressing the superior vena cava. The cyst was resected via median sternotomy, alleviating the patients' preoperative symptoms.

Antibody-directed myostatin inhibition improves diaphragm pathology in young but not adult dystrophic mdx mice.

Duchenne muscular dystrophy (DMD) is characterized by progressive skeletal muscle wasting and weakness, leading to premature death from respiratory and/or cardiac failure. A clinically relevant question is whether myostatin inhibition can improve function of the diaphragm, which exhibits a severe and progressive pathology comparable with that in DMD. We hypothesized that antibody-directed myostatin inhibition would improve the pathophysiology of diaphragm muscle strips from young mdx mice (when the pathology is mild) and adult mdx mice (when the pathology is quite marked). Five weeks treatment with a mouse chimera of anti-human myostatin antibody (PF-354, 10 mg/kg/week) increased muscle mass (P < 0.05) and increased diaphragm median fiber cross-sectional area (CSA, P < 0.05) in young C57BL/10 and mdx mice, compared with saline-treated controls. PF-354 had no effect on specific force (sPo, maximum force normalized to muscle CSA) of diaphragm muscle strips from young C57BL/10 mice, but increased sPo by 84% (P < 0.05) in young mdx mice. In contrast, 8 weeks of PF-354 treatment did not improve muscle mass, median fiber CSA, collagen infiltration, or sPo of diaphragm muscle strips from adult mdx mice. PF-354 antibody-directed myostatin inhibition completely restored the functional capacity of diaphragm strips to control levels when treatment was initiated early, but not in the later stages of disease progression, suggesting that such therapies may only have a limited window of efficacy for DMD and related conditions.

Right ventricular outflow versus apical pacing in pacemaker patients with congestive heart failure and atrial fibrillation.

INTRODUCTION: Prior studies suggest that right ventricular apical (RVA) pacing has deleterious effects. Whether the right ventricular outflow tract (RVOT) is a more optimal site for permanent pacing in patients with congestive heart failure (CHF) has not been established. METHODS AND RESULTS: We conducted a randomized, cross-over trial to determine whether quality of life (QOL) is better after 3 months of RVOT than RVA pacing in 103 pacemaker recipients with CHF, left ventricular (LV) systolic dysfunction (LV ejection fraction < or = 40%), and chronic atrial fibrillation (AF). An additional aim was to compare dual-site (RVOT + RVA, 31-ms delay) with single-site RVA and RVOT pacing. QRS duration was shorter during RVOT (167 +/- 45 ms) and dual-site (149 +/- 19 ms) than RVA pacing (180 +/- 58 ms, P < 0.0001). At 6 months, the RVOT group had higher (P = 0.01) role-emotional QOL subscale scores than the RVA group. At 9 months, there were no significant differences in QOL scores between RVOT and RVA groups. Comparing RVOT to RVA pacing within the same patient, mental health subscale scores were better (P = 0.03) during RVOT pacing. After 9 months of follow-up, LVEF was higher (P = 0.04) in those assigned to RVA rather than RVOT pacing between months 6 and 9. After 3 months of dual-site RV pacing, physical functioning was worse (P = 0.04) than during RVA pacing, mental health was worse (P = 0.02) than during RVOT pacing, and New York Heart Association (NYHA) functional class was slightly better (P = 0.03) than during RVOT pacing. There were no other significant differences between RVA, RVOT and dual-site RV pacing in QOL scores, NYHA class, distance walked in 6 minutes, LV ejection fraction, or mitral regurgitation. CONCLUSION: In patients with CHF, LV dysfunction, and chronic AF, RVOT and dual-site RV pacing shorten QRS duration but after 3 months do not consistently improve QOL or other clinical outcomes compared with RVA pacing.