Neurological Complications in Patients with Infective Endocarditis: Insights from a Tertiary Centre. / Complicações Neurológicas em Pacientes com Endocardite Infecciosa: Perspectivas de um Centro Terciário.

BACKGROUND: Neurological complications are common in patients with infective endocarditis (IE). Recent data suggest that neurologic events are a major determinant of prognosis, and that surgery is critical in improving the outcome. OBJECTIVE: To characterize patients with IE and neurological complications and to determine predictors of embolization to the central nervous system (CNS) and mortality. METHODS: Retrospective analysis of patients admitted to a tertiary center with the diagnosis of IE from 2006 to 2016. Statistical significance was defined by a p-value < 0.05. RESULTS: We identified 148 episodes of IE, 20% of which had evidence of CNS embolization. In patients with CNS embolization, 76% presented with ischemic stroke. During follow-up, 35% were submitted to surgery and both in-hospital and one-year mortality were 39%. These patients had longer hospitalizations, but there were no significant differences regarding mortality in patients with and without CNS embolization. The independent predictors of neurological complications were diabetes (p=0.005) and the absence of fever at presentation (p=0.049). Surgery was associated with lower mortality (0 vs. 58%; p=0.003), while patients with septic shock had a poorer prognosis (75 vs. 25%; p=0.014). In multivariate Cox regression, human immunodeficiency virus (HIV) infection was the only independent predictor of in-hospital and 1-year mortality (p=0.011 in both). CONCLUSIONS: In this population, embolization to the CNS was common, more often presented as ischemic stroke, and was associated with longer hospitalization, although without significant differences in mortality. In patients with CNS embolization, those submitted to surgery had a good clinical evolution, while patients with septic shock and HIV infection had a worse outcome. These results should be interpreted with caution, taking into consideration that patients with more severe complications or more fragile were probably less often considered for surgery, resulting in selection bias.

FUNDAMENTO: Complicações neurológicas são comuns em pacientes com endocardite infecciosa (EI). Dados recentes sugerem que os eventos neurológicos são os principais determinantes do prognóstico e que a cirurgia é crítica para melhorar o resultado. OBJETIVO: Caracterizar pacientes com EI e complicações neurológicas e determinar preditores de embolização para o sistema nervoso central (SNC) e mortalidade. MÉTODOS: Análise retrospectiva de pacientes internados em centro terciário com diagnóstico de EI no período de 2006 a 2016. Significância estatística foi definida por um valor de p <0,05. RESULTADOS: Identificamos 148 episódios de EI, 20% dos quais tinham evidências de embolização do SNC. Em pacientes com embolização do SNC, 76% apresentaram acidente vascular cerebral isquêmico. Durante o seguimento, 35% foram submetidos à cirurgia e a mortalidade hospitalar e em um ano foi de 39%. Esses pacientes tiveram hospitalizações mais longas, mas não houve diferenças significativas em relação à mortalidade em pacientes com e sem embolização do SNC. Os preditores independentes de complicações neurológicas foram diabetes (p = 0,005) e ausência de febre na apresentação (p = 0,049). A cirurgia foi associada a menor mortalidade (0 vs. 58%; p = 0,003), enquanto os pacientes com choque séptico tiveram pior prognóstico (75 vs. 25%; p = 0,014). Na regressão multivariada de Cox, a infecção pelo vírus da imunodeficiência humana (HIV) foi o único preditor independente de mortalidade hospitalar e de 1 ano (p = 0,011 em ambos). CONCLUSÕES: Nessa população, a embolização para o SNC foi comum, mais frequentemente apresentada como acidente vascular cerebral isquêmico, e esteve associada a maior tempo de internação, embora sem diferenças significativas na mortalidade. Nos pacientes com embolização do SNC, os submetidos à cirurgia tiveram boa evolução clínica, enquanto os pacientes com choque séptico e infecção pelo HIV tiveram pior evolução. Esses resultados devem ser interpretados com cautela, levando em consideração que os pacientes com complicações mais graves ou mais frágeis foram provavelmente menos considerados para a cirurgia, resultando em viés de seleção.

Complicações Neurológicas em Pacientes com Endocardite Infecciosa: Perspectivas de um Centro Terciário / Neurological Complications in Patients with Infective Endocarditis: Insights from a Tertiary Centre

Resumo Fundamento: Complicações neurológicas são comuns em pacientes com endocardite infecciosa (EI). Dados recentes sugerem que os eventos neurológicos são os principais determinantes do prognóstico e que a cirurgia é crítica para melhorar o resultado. Objetivo: Caracterizar pacientes com EI e complicações neurológicas e determinar preditores de embolização para o sistema nervoso central (SNC) e mortalidade. Métodos: Análise retrospectiva de pacientes internados em centro terciário com diagnóstico de EI no período de 2006 a 2016. Significância estatística foi definida por um valor de p <0,05. Resultados: Identificamos 148 episódios de EI, 20% dos quais tinham evidências de embolização do SNC. Em pacientes com embolização do SNC, 76% apresentaram acidente vascular cerebral isquêmico. Durante o seguimento, 35% foram submetidos à cirurgia e a mortalidade hospitalar e em um ano foi de 39%. Esses pacientes tiveram hospitalizações mais longas, mas não houve diferenças significativas em relação à mortalidade em pacientes com e sem embolização do SNC. Os preditores independentes de complicações neurológicas foram diabetes (p = 0,005) e ausência de febre na apresentação (p = 0,049). A cirurgia foi associada a menor mortalidade (0 vs. 58%; p = 0,003), enquanto os pacientes com choque séptico tiveram pior prognóstico (75 vs. 25%; p = 0,014). Na regressão multivariada de Cox, a infecção pelo vírus da imunodeficiência humana (HIV) foi o único preditor independente de mortalidade hospitalar e de 1 ano (p = 0,011 em ambos). Conclusões: Nessa população, a embolização para o SNC foi comum, mais frequentemente apresentada como acidente vascular cerebral isquêmico, e esteve associada a maior tempo de internação, embora sem diferenças significativas na mortalidade. Nos pacientes com embolização do SNC, os submetidos à cirurgia tiveram boa evolução clínica, enquanto os pacientes com choque séptico e infecção pelo HIV tiveram pior evolução. Esses resultados devem ser interpretados com cautela, levando em consideração que os pacientes com complicações mais graves ou mais frágeis foram provavelmente menos considerados para a cirurgia, resultando em viés de seleção.

Background: Neurological complications are common in patients with infective endocarditis (IE). Recent data suggest that neurologic events are a major determinant of prognosis, and that surgery is critical in improving the outcome. Objective: To characterize patients with IE and neurological complications and to determine predictors of embolization to the central nervous system (CNS) and mortality. Methods: Retrospective analysis of patients admitted to a tertiary center with the diagnosis of IE from 2006 to 2016. Statistical significance was defined by a p-value < 0.05. Results: We identified 148 episodes of IE, 20% of which had evidence of CNS embolization. In patients with CNS embolization, 76% presented with ischemic stroke. During follow-up, 35% were submitted to surgery and both in-hospital and one-year mortality were 39%. These patients had longer hospitalizations, but there were no significant differences regarding mortality in patients with and without CNS embolization. The independent predictors of neurological complications were diabetes (p=0.005) and the absence of fever at presentation (p=0.049). Surgery was associated with lower mortality (0 vs. 58%; p=0.003), while patients with septic shock had a poorer prognosis (75 vs. 25%; p=0.014). In multivariate Cox regression, human immunodeficiency virus (HIV) infection was the only independent predictor of in-hospital and 1-year mortality (p=0.011 in both). Conclusions: In this population, embolization to the CNS was common, more often presented as ischemic stroke, and was associated with longer hospitalization, although without significant differences in mortality. In patients with CNS embolization, those submitted to surgery had a good clinical evolution, while patients with septic shock and HIV infection had a worse outcome. These results should be interpreted with caution, taking into consideration that patients with more severe complications or more fragile were probably less often considered for surgery, resulting in selection bias.

An unexpected association in a patient with heart failure presenting a surgical challenge.

Bicuspid aortic valve (BAV) is the most common form of congenital heart disease and frequently leads to premature valvular dysfunction. BAV is associated with aortic wall abnormalities and a high prevalence of ascending aorta dilatation and coarctation of the aorta (CoA). Consequently, in patients with BAV a careful assessment of the valve, and also of the aortic root and the ascending aorta, should be performed. The most feared complication is aortic dissection, however, the actual incidence of this complication is low. We report the case of a 58-year-old man who presented with New York Heart Association class III heart failure. The work-up revealed BAV with severe stenosis and severe compromise of left ventricle systolic function. In addition, CoA in the isthmus region, and type B dissection of the aorta were diagnosed.

Three cases of pregnancy in patients with severe pulmonary arterial hypertension: experience of a single unit.

Pregnancy in patients with severe pulmonary arterial hypertension is a high risk situation, which makes pregnancy prevention or termination in the first trimester advisable. For this reason, patients of reproductive age with this pathology are referred for gynecology consultation. Since our unit began operating in 1999, we have had three pregnant patients with severe pulmonary arterial hypertension--one our patient and the other two referred from other centers. In this article we describe these three cases and review the literature on pregnancy and pulmonary arterial hypertension.

The role of echocardiography in assessing parachute mitral valve.

Treadmill exercise echocardiography with Doppler evaluation during effort has been used for several years in our department. The usefulness of this methodology in the management of patients with coronary heart disease is recognized but it is being increasingly used in patients with valvular heart disease. We report the case of a 44-year-old man with parachute mitral valve, in which transesophageal echocardiography characterized the pathology and exercise stress echocardiography was important for accurate functional assessment and clinical decisions.

Echocardiography during treadmill exercise testing in a patient with mitral stenosis.

Treadmill exercise echocardiography with Doppler during effort has been used for several years in our department. This form of echocardiography is used mainly in evaluation of patients with coronary heart disease and it is being increasingly used in valvular heart disease. We report the case of a 49-year-old woman with moderate mitral stenosis, in which stress echocardiography was important in making correct clinical decisions.

Echocardiography during treadmill exercise testing for evaluation of pulmonary artery systolic pressure: advantages of the method.

INTRODUCTION: Determination of pulmonary artery systolic pressure by Doppler echocardiography (based on the pressure gradient between the right ventricle and right atrium - DeltaP RV/RA) or by right heart catheterization is useful in evaluating the severity and prognosis of cardiac disease. The aim of the study was to evaluate DeltaP RV/RA non-invasively during treadmill exercise in patients with tricuspid regurgitation and without coronary artery disease. METHODS: Of a total of 149 patients referred to our echo laboratory, we completed the study in 142 (95%), of whom 120 were women, mean age 52+/-13 years (23 to 82). We studied 68 patients with valvular heart disease (of whom 56 had mitral valve stenosis and sinus rhythm on ECG), 42 with systemic sclerosis, 10 with severe pulmonary hypertension, 12 with a history of pulmonary embolism and 10 healthy controls. The DeltaP RV/RA was determined from the tricuspid regurgitation jet using continuous wave Doppler in left lateral decubitus (LLD) before exercise testing (BLLD), in a standing position (SP), at peak workload (PW) before termination of the test, and in the first 60 seconds of the recovery period in LLD (RLLD). RESULTS: The DeltaP RV/RA in BLLD was 36+/-21 mmHg (range 18 to 147); the SP [symbol: see text]P RV/RA was 32+/-24 mmHg (range 12 to 137), p<0.001 vs. BLLD DeltaP RV/RA; the PW DeltaP RV/RA was 58+/-26 mmHg (range 28 to 177), p<0.0001 vs. SP DeltaP RV/RA; and the RLLD DeltaP RV/RA was 47+/-25 mmHg (range 20 to 152), p<0.001 vs. PW DeltaP RV/RA. The differences between PW DeltaP RV/RA and RLLD DeltaP RV/RA changed therapeutic decisions in 10 patients (18%) with mitral stenosis, and modified the management of 13 patients (30%) with systemic sclerosis (who then underwent right heart catheterization). CONCLUSIONS: Echocardiography during treadmill exercise testing was feasible in most patients. The DeltaP RV/RA decreases in response to the standing position. The DeltaP RV/RA rises considerably with exercise in the majority of patients and is significantly higher at peak workload than in the recovery period. The differences between PW DeltaP RV/RA and RLLD DeltaP RV/RA influenced patient management.

Syncope caused by severe hypotension and intraventricular gradient during dobutamine stress echocardiography.

Dobutamine stress echocardiography is widely used for the evaluation of coronary artery disease. This form of stress echocardiography is safe but not without complications. We report a case of hypotension and syncope during dobutamine stress echocardiography in which a severe intraventricular gradient of over 200 mmHg and systolic anterior movement of the mitral valve were observed.

Evaluation of left ventricular outflow tract gradient during treadmill exercise and in recovery period in orthostatic position, in patients with hypertrophic cardiomyopathy.

BACKGROUND: Left ventricular outflow tract obstruction is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). The classical quantification of intraventricular obstruction is performed in resting conditions in supine position, but this assessment does not reflect what happens in HCM patients (pts) in their daily activities, neither during effort nor during orthostatic recovery. AIM: To assess intraventricular gradients with echocardiography during treadmill exercise and in the recovery period in upright position, in HCM pts. METHODS: We studied 17 HCM pts (9 males, mean age 53 +/- 16 years, 11 with obstructive HCM). Each pt had 2 echocardiographic evaluations at rest (left lateral decubitus (LLD) and orthostatic position). The pts then underwent a treadmill exercise test and intraventricular gradients were measured at peak exercise and during recovery in orthostatic position. RESULTS: 3 pts with non-obstructive HCM at rest developed intraventricular gradients during exercise. 1 pt developed this gradient only during orthostatic recovery. The mean intraventricular gradient in LLD was 49 +/- 24 mmHg; in orthostatic position was 62 +/- 29 mmHg (p < 0.001 versus in LLD); at peak exercise was 83 +/- 35 mmHg (p < 0.001 versus supine rest); during recovery it was 96 +/- 35 mmHg (p < 0.001 versus peak exercise) CONCLUSION: In HCM pts the intraventricular gradient increases in orthostatic position, increases significantly during treadmill exercise and continues increasing in the recovery period in orthostatic position. This type of evaluation can help us to better understand the physiopathology, the symptoms and the efficacy of different therapeutic modalities in this disease and should be routinely used in the assessment of HCM pts.

Should right ventricle dilatation during exercise have clinical implications in patients with chronic thromboembolic pulmonary hypertension? Case report.

We describe the case of a 30-year-old female patient with chronic thromboembolic pulmonary hypertension that has an excellent functional capacity under treatment with sildenafil. She did an exercise stress echocardiography that revealed marked right ventricular dilatation during exercise. This information was used for clinical decision and the authors discuss the potential utility of this echocardiographyc sign.

Acute hemodynamic effect of inhaled iloprost in pulmonary artery hypertension evaluated with echocardiography.

Doppler echocardiography is useful in the initial evaluation and long-term follow-up of patients with pulmonary artery hypertension. Aerosolised iloprost has been shown to reduce pulmonary pressure immediately after inhalation. We report the echocardiographic findings in a patient with severe pulmonary hypertension, before and after the inhalation of aerosolized iloprost. These findings illustrate the acute influence of iloprost in right and left ventricular hemodynamics and morphology. These findings were reproduced in subsequent echocardiographic evaluations.

Evaluation of systolic and systo-diastolic function: the Tei index in acute myocardial infarction treated with acute reperfusion therapy--early and late evaluation.

INTRODUCTION: Evaluation of systolic and diastolic function by non-invasive methods in the acute phase of myocardial infarction (MI) is of great importance for risk stratification and prognosis. Ejection fraction (EF), as determined by echocardiography using the Simpson method, is the main parameter for assessing left ventricular (LV) function. The Tei index (TI), a Doppler-derived index that reflects systolic and diastolic function in MI, has an excellent correlation with prognosis. OBJECTIVE: The purpose of this study was to evaluate systolic and systo-diastolic function in the acute and late phase of ST-elevation MI treated with acute reperfusion therapy. METHODS: Patients with ST-elevation MI who underwent acute reperfusion therapy were evaluated by echocardiography in the first 48 hours and after one week. The parameters studied were: EF, wall motion score index (WMSI), and TI. The values obtained at the first and second evaluation were compared and correlated with pain to reperfusion time (PRT) (<3 vs. > or =3 hours), presence of single or multivessel disease, ejection fraction, total CK (<1500 or > or =1500 UI/l), and MI location (anterior vs. other). RESULTS: 40 patients were studied and 19 were included, of whom 15 (80%) were male, mean age 57 +/- 14 years. Risk factors included hypertension (11 patients, 58%), smoking (14, 74%), diabetes (6, 30%), and dyslipidemia (12, 63%). MI location was anterior in 6 patients (32%) and inferior in 13 (68%). Five patients (26%) underwent fibrinolysis and 14 (74%) direct percutaneous coronary intervention. Mean pain to reperfusion time was 3.7 +/- 2.8 hours. Four patients (21%) had single vessel disease and 14 (74%) multivessel disease. Significant differences were found: (a) in mean EF and WMSI between the two evaluations (p < 0.0001 and p = 0.002 respectively); (b) between PRT and EF (p = 0.001) and WMSI (p = 0.020) at 48 hours; (c) between PRT and EF (p = 0.01) and TI (p = 0.033), and MI location and EF (p = 0.005) after one week. DISCUSSION AND CONCLUSIONS: Early systolic function and LV remodeling one week after MI were accurately evaluated by EF and WMSI. Early reperfusion therapy positively influences early and late systolic and systo-diastolic function.

Exercise-induced left ventricular outflow tract obstruction. A potential cause of symptoms in the elderly.

We describe a 79-year-old male patient with no significant risk factors for coronary heart disease besides age and gender. He was referred for cardiology consultation because of effort dyspnea. Diagnostic exams including laboratory tests, chest X-ray, ECG and resting echocardiogram showed no abnormalities. He underwent exercise stress echocardiography, which revealed reduced exercise tolerance and a dynamic left ventricular outflow tract obstruction with an intraventricular gradient of over 50 mmHg. No segmental wall motion abnormalities were observed. He was treated with the beta-blocker bisoprolol 5 mg qd, with significant clinical improvement. Two years later exercise stress echocardiography was repeated and better functional capacity was apparent, with no intraventricular gradient during peak exercise. The authors discuss the clinical importance of this unsuspected cause of symptoms in the elderly.

Acute resynchronization with inhaled iloprost in a pregnant woman with idiopathic pulmonary artery hypertension.

We describe the case of a pregnant woman with idiopathic pulmonary arterial hypertension, a responder in right heart catheterization, followed since the first trimester in outpatient consultations, admitted to hospital at 23 weeks gestation. She was treated with inhaled iloprost until delivery (at 34 weeks gestation) and continuous infusion of iloprost throughout the perioperative period and following days. This line of therapy has proved efficacious in previous cases. The authors present echocardiographic images that document acute changes in ventricular synchrony during inhalation of iloprost.

Left pulmonary artery evaluation through transesophageal echocardiography.

INTRODUCTION: Transesophageal echocardiography (TEE) has become increasingly useful in the study of patients with suspected pulmonary thromboembolism. OBJECTIVE: The aim of this study was to prospectively evaluate the usefulness of TEE in the study of the distal part of the left pulmonary artery (LPA) as well as the influence of this procedure on total echocardiographic exam duration. METHODOLOGY: A prospective study in two groups of consecutive patients referred for TEE with a one- year interval between evaluation of Group A: 33 patients, 17 male, mean age 54 +/- 24 years, and Group B: 42 patients, 20 male, mean age 48 +/- 27 years (p = NS). The procedure was considered long when it took more than 3 min to evaluate the distal part of the LPA. RESULTS: In group A we were able to visualize the distal part of the LPA in 24 patients (73%) without significant prolongation of total exam duration in 16 patients (48% of group A). In one of the patients with suspected pulmonary thromboembolism thrombi were only observed in the distal part of the LPA. In group B we were able to visualize the distal part of the LPA in 36 patients (86%) without significant prolongation of total exam duration in 26 patients (61% of group B). CONCLUSIONS: 1. Visualization of the distal part of the LPA was possible in more patients, and with TEE time prolongation in less patients, in group B. These differences can be accounted for by the training of the operator in this technique. 2. The importance of visualization of this part of the LPA in guiding treatment in the subset of patients with pulmonary thromboembolism confirms the usefulness of this specific procedure.

Exercise stress echocardiography for detection of pulmonary arterial hypertension in a patient with systemic sclerosis.

The authors report the case of a 57-year-old patient, diagnosed with systemic sclerosis 16 years ago. She had been followed in the rheumatology outpatient clinic since 2003 and complained of marked fatigue and dyspnea on exertion. In addition to full medical evaluation, she also underwent standard Doppler echocardiography at rest, which was unremarkable, and exercise stress echocardiography. In the latter examination, she was diagnosed with pulmonary arterial hypertension, later confirmed during right heart catheterization. The authors discuss the potential value of this methodology for the study of patients with systemic sclerosis.