Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis.

INTRODUCTION AND OBJECTIVES: Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. METHODS: From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. RESULTS: The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. CONCLUSIONS: Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

3D Virtual modelling, 3D printing and extended reality for planning of implant procedure of short-term and long-term mechanical circulatory support devices and heart transplantation.

Introduction: The use of three-dimensional (3D) reconstruction and printing technology, together with extended reality applied to advanced heart failure adult patients with complex anatomy, is rapidly spreading in clinical practice. We report practical experience with application to acute and chronic heart failure: planning and performing mechanical circulatory device insertion or heart transplantation. Methods: From November 2019 until February 2022, 53 3D virtual biomodels were produced for intervention planning (using Virtual/Augmented Reality and/or 3D printing), following a specific segmentation and preprocessing workflow for biomodelling, in patients with advanced heart failure due to structural heart disease or cardiomyopathies. Four of those patients were complex cases requiring mechanical circulatory support implant procedures in our center. Results: One short-term and three long-term ventricular assist device system were successfully clinically implanted after application of this technique. In other two cases with extremely high procedural risk, visualized after application of this multimodality imaging, heart transplantation was elected. Conclusion: 3D printing based planning and virtual procedure simulation, are of great importance to select appropriate candidates for mechanical circulatory support in case of complex patient anatomy and may help to diminish periprocedural complications. Extended reality represents a perspective tool in planification of complex surgical procedures or ventricular assist device insertion in this setting.

Challenges in cannulation of left ventricular apex for temporary circulatory support: a case report.

Apical cannulation of a left ventricle for temporary support is still challenging, especially in case of prolonged support due to donor organ shortage. Traditional cannulation techniques with the cannula being directly inserted into the left ventricle cavity are technically easy, but prone to hemorrhage during circulatory support, unsafe for a prolonged support (over than 30 days) and limits the possibility to ambulate patient due to risk for cannula dislocation and related life-threatening bleeding. We describe a case of temporary left ventricular assist device placement in a 59-year-old male patient being on veno-arterial extracorporeal membrane oxygenation support secondary to acute myocardial infarction. We present a very simple technique to secure insertion of an apical left ventricular cannula using patch of soft Teflon felt. Handmade created apical soft Teflon cuff is than fixed using twelve 4/0 prolene sutures supported with pledgets. This gives better fixation to apical myocardium (especially in case of fragile tissue after acute infarction) and secure intracavitary length of inflow cannula in a controlled mode, thus better than purse-string sutures only. Using anti-adhesive membrane, further dissection during heart transplant procedure was uneventful. This technique allowed safe circulatory support and patient ambulation in the ward during 85 days until heart transplantation.

Atrial fibrillation in patients with SARS-CoV-2 infection.

INTRODUCTION AND OBJECTIVE: the SARS-CoV-2 infection ranges from asymptomatic to critical forms and several prognostic factors have been described. Atrial fibrillation (AF) is common in acute situations where it is linked with more complications and mortality. We aimed to evaluate the prognostic information of AF in this population. METHODS: retrospective analysis of a cohort of 517 patients consecutively admitted in a tertiary hospital due to SARS-CoV-2 infection. We divided the patients in two groups according the development of AF and compared the main features of both groups. An univariable and multivariable analysis of mortality were also performed. RESULTS: among 517 patients with SARS-CoV-2 infection admitted in a tertiary center, 54 (10.4%) developed AF. These patients are older (81.6 vs 66.5 years old, p < 0.001) and present more hypertension (74% vs 47%, p < 0.001), cardiomyopathy (9% vs 1%, p = 0.002), previous heart failure admission (9% vs 0.4%, p < 0.001), previous episodes of AF (83% vs 1%, p < 0.001) and bigger left atrium (47.8 vs 39.9 mm, p < 0.001). AF COVID-19 patients present more acute respiratory failure (72% vs 40%, p < 0.001) and higher in-hospital mortality (50% vs 22%, p < 0.001). Predictors of AF development are age and previous AF. AF is not an independent predictor of in-hospital mortality. Predictors are age, creatinine > 1.5 mg/dL at admission, LDH > 250 UI/L at admission and acute respiratory failure. CONCLUSION: Atrial fibrillation appears in 10% of hospitalized patients with SARS-CoV-2 infection. These patients present more comorbidities and two-fold increase in hospital mortality. Atrial fibrillation is not an independent prognostic factor.

INTRODUCCIÓN Y OBJETIVO: La infección por SARS-CoV-2 presenta un amplio espectro clínico, y varios factores pronósticos han sido descritos. La fibrilación auricular (FA) es frecuente en situaciones agudas, donde se ha relacionado con aumento de complicaciones y mortalidad. Nuestro objetivo ha sido evaluar el impacto pronóstico de la FA en esta población. MÉTODOS: Análisis retrospectivo de una cohorte de 517 pacientes con infección SARS-CoV-2 consecutivamente ingresados en un hospital terciario. Dividimos a los pacientes en dos grupos de acuerdo al desarrollo de FA durante el ingreso y comparamos las características de los grupos. Realizamos análisis univariado y multivariado de mortalidad. RESULTADOS: De los 517 pacientes, 54 (10,4%) desarrollaron FA. Estos pacientes son mayores (81,6 vs. 66,5 años, p < 0,001) y presentan más hipertensión (74% vs. 47%, p < 0,001), miocardiopatía (9% vs. 1%, p = 0,002), ingreso previo por insuficiencia cardiaca (9% vs. 0,4%, p < 0,001), historia de FA (83% vs. 1%, p < 0,001) y mayor aurícula izquierda (47,8 vs. 39,9 mm, p < 0,001). Los pacientes con FA presentan más fallo respiratorio agudo (72% vs. 40%, p < 0,001) y mayor mortalidad hospitalaria (50% vs. 22%, p < 0,001). Los predictores de FA son la edad y la historia de FA previa. La FA no es un predictor independiente de mortalidad hospitalaria. Los predictores son: edad, creatinina > 1,5 mg/dL al ingreso, LDH > 250 U/L al ingreso y el fallo respiratorio agudo. CONCLUSIÓN: La FA aparece en el 10% de los pacientes hospitalizados por SARS-CoV-2. Estos presentan mayor comorbilidad y el doble de mortalidad hospitalaria, pero la FA no es un factor pronóstico independiente.

Atrial fibrillation in patients with SARS-CoV-2 infection.

INTRODUCTION AND OBJECTIVE: the SARS-CoV-2 infection ranges from asymptomatic to critical forms and several prognostic factors have been described. Atrial fibrillation (AF) is common in acute situations where it is linked with more complications and mortality. We aimed to evaluate the prognostic information of AF in this population. METHODS: retrospective analysis of a cohort of 517 patients consecutively admitted in a tertiary hospital due to SARS-CoV-2 infection. We divided the patients in two groups according the development of AF and compared the main features of both groups. An univariable and multivariable analysis of mortality were also performed. RESULTS: among 517 patients with SARS-CoV-2 infection admitted in a tertiary center, 54 (10.4%) developed AF. These patients are older (81.6 vs 66.5 years old, p<0.001) and present more hypertension (74% vs 47%, p<0.001), cardiomyopathy (9% vs 1%, p=0.002), previous heart failure admission (9% vs 0.4%, p<0.001), previous episodes of AF (83% vs 1%, p<0.001) and bigger left atrium (47.8 vs 39.9mm, p<0.001). AF COVID-19 patients present more acute respiratory failure (72% vs 40%, p<0.001) and higher in-hospital mortality (50% vs 22%, p<0.001). Predictors of AF development are age and previous AF. AF is not an independent predictor of in-hospital mortality. Predictors are age, creatinine>1.5mg/dL at admission, LDH>250UI/L at admission and acute respiratory failure. CONCLUSION: Atrial fibrillation appears in 10% of hospitalized patients with SARS-CoV-2 infection. These patients present more comorbidities and two-fold increase in hospital mortality. Atrial fibrillation is not an independent prognostic factor.

Infective endocarditis in patients with aortic grafts.

BACKGROUND: Infective endocarditis (IE) in patients with a valve-tube ascending aortic graft (AAG) is a rare entity with a challenging diagnosis and treatment. This study describes the clinical features, diagnosis and outcome of these patients. METHODS: Between 1996 and 2019, 1654 episodes of IE were recruited in 3 centres, of which 37 patients (2.2%) had prosthetic aortic valve and AAG-IE (21 composite valve graft, 16 supracoronary graft) and conformed our study group. RESULTS: Patients with aortic grafts were predominantly male (91.9%) and the mean age was 67.7 years. Staphylococci were the most frequently isolated microorganisms (32%). Viridans group streptococci were only isolated in patients with composite valve graft. TEE was positive in 89.2%. PET/CT was positive in all 15 patients in whom it was performed. Surgical treatment was performed in 62.2% of patients. In-hospital mortality was 16.2%. Heart failure and the type of infected graft (supracoronary aortic graft) were associated with mortality. Mortality among operated patients was 21.7%. Interestingly, 14 patients received antibiotic therapy alone, and only one died. Mortality was lower among patients with a composite valve graft compared to those with a supracoronary graft (4.8% vs 31.3%; p = 0.03). CONCLUSIONS: In patients with AAG and prosthetic aortic valve IE, mortality is not higher than in other patients with prosthetic IE. Multimodality imaging plays an important role in the diagnosis and management of these patients. Heart failure and the type of surgery were risk factors associated with in-hospital mortality. Although surgical treatment is usually recommended, a conservative management might be a valid alternative treatment in selected patients.

Quantitative flow ratio-Meta-analysis and systematic review.

INTRODUCTION: Despite of the wide evidence of use fractional flow reserve (FFR), isolated angiography evaluation is still the main tool to indicate percutaneous coronary intervention. Quantitative flow ratio (QFR) is a new functional index to assess functional significance. Recently, few studies have showed the capacity of QFR to predict significance stenosis. The aim of this research has been to describe the evidence of QFR in this clinical setting, to analyze the global diagnosis accuracy of QFR versus FFR and to compare the difference in feasibility between retrospective and prospective analysis. METHODS AND RESULTS: Systematic review of literature was performed. Eligible studies for the meta-analysis were considered those directly evaluating de QFR versus FFR. Pooled values of diagnosis test and summary receiver operator curve were calculated. Main causes of not-perform QFR analysis according to study design were also evaluated. Sixteen studies were included. Good correlation and agreement were showed. Global sensibility, specificity, PPV, and NPV were 0.84, 0.89, 0.80, and 0.92, respectively. Then, 18% of evaluated vessels could not be analyzed. Significant differences were found in the percentage of discarded vessels and the cause of nonperformed analysis between retrospective or prospective analysis. CONCLUSIONS: Excellent correlation and agreement between QFR and FFR was demonstrated. QFR assessment could be improved by its prospective analysis with a dedicated protocol.

Twitter and the pursuit of global health-care during COVID-19 pandemic / Twitter y la búsqueda de una atención sanitaria global durante la pandemia COVID-19

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The 'wait for symptoms' strategy in asymptomatic severe aortic stenosis.

Calcific aortic stenosis is a prevalent and worrisome healthcare problem. The therapeutic approach in asymptomatic aortic stenosis is not well established. We argue that the natural history of this disease is based on old incomplete studies with many limitations. Likewise, studies suggesting that replacement, either surgical or percutaneous, improves prognosis in asymptomatic patients with severe aortic stenosis have important drawbacks and do not support this strategy as the treatment of choice. Despite the lack of evidence, some groups recommend early valve replacement in patients with severe asymptomatic aortic stenosis. There are five ongoing randomised trials which will shed light on this topic. Our conclusion is that unless a randomised study changes the evidence, valve replacement cannot be recommended in asymptomatic patients with severe aortic stenosis.

Trombosis masiva en estrategia con ECPELLA / Massive thrombosis in ECPELLA strategy

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Long-term results after reconstruction of a new annulus in heavily calcified mitral annulus.

BACKGROUND AND AIM OF THE STUDY: In 2009 our group described a new surgical technique for patients with severe mitral valve calcification undergoing mitral valve surgery. This technique creates a new mitral annulus with plication of the mitral leaflet and the atrial wall. Our objective is to report the long-term results of the experience at our institution. MATERIALS, METHODS, AND RESULTS: From 2007 to 2016, a total of 18 patients (mean age 70.5 ± 7.8 years) underwent mitral valve replacement at our institution with this technique. One patient died on the second postoperative day. Clinical and echocardiographic in-hospital and long-term follow-up (55.5 ± 40.4 months) were performed on all the remaining 17 patients. Functional improvement was achieved in all patients. Two patients died 6 and 8 years after surgery (cancer and hemorrhagic stroke). No prosthetic dysfunction, periprosthetic leak, or annular dehiscence were detected in the long-term echocardiographic examinations. CONCLUSIONS: The reconstruction of the mitral annulus by using our technique in patients with severe calcification of the mitral annulus has low long-term mortality, good functional results, and a lack of prosthetic complications.