Clinical features and outcomes of infective endocarditis: a single-centre experience.

BACKGROUND: Infective endocarditis (IE) may present with a broad spectrum of symptoms and signs and several tools can be used for diagnosis. Many protocols can be used for in-hospital and out-patient management. The aim of this study was to assess the clinical features, tools used and outcomes of patients diagnosed with IE in one of the tertiary-care university hospitals. METHODS: This study included 90 consecutive patients admitted to the Cardiology Department in a tertiary-care university hospital in Egypt with a diagnosis of IE. RESULTS: The mean age of the studied population was 36.72 years and 76.67% were males. The most common underlying condition was valvular heart disease (48.89%), followed by intravenous drug use (26.67%) and the most common risk factor was smoking (48.89%). The most common clinical presentation was fever (69.67%), followed by dyspnoea (55.56%), and the mean duration from symptom onset until admission was 13.28 ± 9.29 days. Positive cultures were encountered in 45.56% of patients. Surgery was indicated in 91.11% of the patients but it was performed in only 28.89%. Almost a third of patients (34.44%) died in the hospital. After one year of follow up, a further 8.47% of the patients had died, 11.86% had heart failure and 6.78% had undergone a re-do surgery. CONCLUSIONS: Nowadays IE tends to affect a younger group of patients and valvular heart disease is the main underlying condition. The mortality rate due to IE is high in developing countries and IE does not have only immediate and short-term complications, its effects extend to a longer period of time.

The impact of asymptomatic ventricular arrhythmias on the outcome of heart failure patients with reduced ejection fraction.

BACKGROUND: Ventricular arrhythmias cause a significant proportion of sudden deaths. Several studies demonstrate a high prevalence of ventricular arrhythmias in patients with heart failure regardless of the etiology. The aim of this study was to determine the prevalence of silent ventricular arrhythmias in ambulatory heart failure patients with reduced left ventricular ejection fraction (HFrEF) and its correlation to the prognosis. RESULTS: Four hundred (400) ambulatory HFrEF patients on maximum tolerated doses of heart failure medications were included. Holter monitoring for 7 days was done in all patients searching for silent ventricular arrhythmias. The patients were followed-up for one year to detect the occurrence of major adverse cardiovascular events. We divided the study population into 2 groups based on an LVEF cutoff value of 30% (Group A < 30%, Group B ≥ 30%). Holter monitoring revealed ventricular arrhythmias in 304 patients. Patients with left ventricular ejection fraction (EF) < 30% (Group A) had more complex ventricular arrhythmias in the form of frequent Premature ventricular contractions (PVCs) of ≥ 5% and or non-sustained ventricular tachycardia (NSVT) runs. Furthermore, Among Group A, more major cardiovascular events were observed. Multivariate regression analysis showed that frequent PVCs and severely reduced LVEF were the strongest independent predictors of major cardiovascular events. CONCLUSIONS: ventricular arrhythmias are common in HFrEF patients even in the compensated status. Both, left ventricular systolic function and the PVCs burden were found to be the strongest predictors of major adverse cardiovascular events.

Cleft posterior mitral valve leaflet: The added value of 3-dimensional echocardiography.

A 65-year-old female patient diagnosed with degenerative aortic valve disease and severe regurgitation on transthoracic echocardiography (TTE) also had severe mitral regurgitation (MR), but the exact mechanism of MR could not be determined. Transesophageal echocardiography (TEE) showed limited leaflet coaptation and a severe central MR jet. Further three-dimensional (3D) imaging revealed an indentation in the middle of P2 scallop almost reaching the annulus. This was consistent with the diagnosis of cleft posterior mitral valve leaflet. Unlike cleft anterior leaflet which can be clear on TTE short-axis images, cleft posterior leaflet may only be visible using 3D TEE. The identification of cleft posterior leaflet is essential in guiding surgical valve repair.

A Life-Threatening Presentation of Primary Small Cell Colorectal Non-Hodgkin Lymphoma as Cardiac Tamponade and Its Challenging Management.

Colorectal non-Hodgkin lymphoma (NHL) is quite aggressive and rare, only constituting less than 1% of all cases of colorectal cancer. The pericardium is an extremely rare first site of metastasis. Cardiac tamponade can be a life-threatening initial presentation. We report a 55-year-old female who presented with severe shortness of breath, intermittent abdominal pain and altered bowel habits. She had low blood pressure with congested neck veins. Her echocardiogram showed pericardial and cardiac infiltration with tumour mass; a large pericardial effusion with signs of cardiac tamponade. There was no safe window for percutaneous drainage, and the patient was not physically fit for surgical drainage. A multidisciplinary approach was used to diagnose and manage the case involving a cardiologist, gastroenterologist, pathologist, radiologist and oncologist. CT scans of the whole body showed a large rectosigmoid mass infiltrating the uterus and adnexa. Flexible sigmoidoscopy showed a large bleeding mass at the rectosigmoid junction. The biopsy confirmed small cell NHL. Three cycles of chemotherapy were urgently commenced over a period of 5 weeks (1 cycle of CVP; 2 cycles of CHOP). The patient showed significant symptomatic improvement. A 5-week follow-up echocardiogram showed significant shrinkage of the pericardial tumour and only a small rim of pericardial effusion. The effusion did not recollect in her follow-up echocardiograms. A year later, she was referred to the palliative care team due to the further spreading of her lymphoma. In conclusion, colorectal small cell NHL may initially present as cardiac tamponade. Urgent initiation of chemotherapy can be a treatment option whenever a drainage procedure is unsafe. LEARNING POINTS: Colorectal small cell NHL is a quite rare malignancy that may present initially with pericardial metastasis.Cardiac tamponade secondary to colorectal NHL is a life-threatening presentation. It can be managed by timely chemotherapy alone whenever the usual drainage procedures are not safe.A multidisciplinary approach is a cornerstone in the management of unstable lymphoma patients. It helps the rapid diagnosis and initiation of appropriate chemotherapy.

Complex and multilevel left ventricular outflow tract obstruction: What can 3D echocardiography add?

BACKGROUND: Subaortic obstruction by a membrane or systolic anterior motion of the mitral valve leaflets is usually suspected in young patients, especially if the anatomy of the aortic valve is not clearly stenotic and unexplained left ventricular hypertrophy exists in the context of high transaortic gradients. MAIN BODY: In certain circumstances, some patients show both aortic and subaortic stenotic lesions of variable severity. Doppler echocardiography can help in grading severity in the case of single-level obstruction but not in patients with multilevel obstruction where the continuity equation is of no value. Three-dimensional (3D) echocardiography allows "en-face" visualization of each level of the aortic valve and subaortic tract; in addition, direct planimetry of the areas can be done using multiplanar reformatting. CONCLUSIONS: Accordingly, 3D echocardiography plays a crucial role in the assessment in patients with multilevel left ventricular outflow tract obstruction as it can accurately delineate the location and size, and severity of the stenosis.

Effects of cardiac pacemakers on left ventricular volumes and function assessed by 3D echocardiography, Doppler method, and global longitudinal strain.

BACKGROUND: Many previous studies reported the negative effects of right ventricular (RV) pacing on the left ventricular (LV) structure and ejection fraction. Studying pacing hemodynamics is essential to understand these detrimental effects. In this study, we tried to understand RV pacing effects on LV volumes and function using advanced tools like 3D echo and global longitudinal strain (GLS). This was a prospective study of 175 consecutive patients (LVEF>50%) presented permanent pacing. Of 175 patients, only 50 patients met study criteria, divided into two groups (single or dual pacing). LV volumes and function were assessed by full-volume 3D echocardiography and GLS before pacing, at 1-week and 6-month post-pacing. Cardiac output (COP) was calculated by pulsed wave Doppler method and 3D echo. RESULTS: Doppler method results were similar to 3D echo in calculating SV and COP. At 1-week post pacing, both groups showed a significant decrease in SV due to a drop in EDV while ESV did not change significantly. Despite the drop in SV, there was a significant increase in cardiac output (COP) due to achieving higher heart rates post-pacing. There was a significant drop in EF and GLS in both groups. At 6 months, SV continued to decrease with a corresponding decrease in COP and LVEF. This drop in SV was due to a significant increase in ESV while EDV did not show a significant change at a 6-month follow-up. Also, the drop EF and GLS became more significant. There were no significant differences between both groups regarding the changes in LV volumes (EDV, ESV, SV), LVEF or GLS throughout the study (pre-pacing, at 1-week and 6-months post pacing). However, dual-chamber pacing group provided higher heart rates and as a result higher COP than the single-chamber group. CONCLUSIONS: RV pacing led to a significant drop in LV COP, ejection fraction (EF), and GLS over short- and long-term duration. Dual chamber pacing provided higher COP than a single chamber pacing. This was due to tracking the S. A node with pacing at higher heart rates not due to an increase in SV and preserving atrioventricular synchrony. Both Doppler method and 3D echo can be used to calculate SV and COP.

Predictors of pacing induced left ventricular dysfunction and cardiomyopathy assessed by three-dimensional echocardiography and speckle tracking strain.

BACKGROUND: Long-term RV pacing leads to ventricular dyssynchrony, in the form of LBBB-like morphology, with subsequent detrimental effects on LV structure and function. Three-dimensional echocardiography allowed early detection of volumetric changes associated with PICMP and provided more accurate assessment of mechanical dyssynchrony. Speckle tracking strain is able to identify LV dysfunction even before any reduction in LVEF. Our aim was to study pacing effects on LV function and hemodynamics using 3D echo and speckle tracking strain. RESULTS: This was a prospective study of 175 consecutive patients without structural heart disease (LVEF > 50%) presented for permanent pacing. Full-volume 3D echocardiography done before implantation, 1 week, and 6 months together with GLS. Patients were followed for 6 months to detect incidence of PIVD (defined as reduction in LVEF > 10% but still above 50%) and PICMP (defined as decrease in LVEF by 10% from baseline in absence of other known causes of cardiomyopathy resulting in EF< 50%). PIVD and PICMP predictors and risk factors were analyzed. Only 50 patients met study criteria. Twenty-five (50%) patients developed LV systolic dysfunction; of these, 19 (38%) developed PIVD and 6 (12%) developed PICMP. Pre-implantation GLS was significantly lower in the 6 patients who subsequently developed PICMP, compared to those who developed PIVD and the preserved EF group (mean GLS - 15.50 vs. - 21.0, - 20.0 respectively; p = 0.005, 0.033, respectively). At 1 week, GLS was significantly lower in the 25 patients who subsequently developed PIVD, compared to those who did not (GLS - 13.0 vs. - 18.0, respectively; p = 0.002). A reduction of baseline GLS by 15% or more at 1 week was associated with the development of PIVD and PICMP (p = < 0.001). A wider native QRS complex was associated with PIVD and PICMP (p = 0.008, 0.018, respectively). The other predictors were found non-significant. CONCLUSION: PICMP may be more common than previously reported and it may occur shortly after implantation. Pre-implantation GLS is a sensitive parameter for PICMP. One-week GLS, pre-implantation QRS complex width are early predictors for PICMP and PIVD before any reduction in EF.

Eustachian valve infective endocarditis.

A 40-year-old woman presented with postoperative fever. Echocardiography revealed a large pedunculated cauliflower right atrial mass of heterogeneous echogenicity attached to the eustachian valve measuring about 2×3 cm. She underwent surgical excision, gross and microscopical examination were consistent with eustachian valve infective endocarditis.

Carney Complex: A Rare Case of Multicentric Cardiac Myxoma Associated with Endocrinopathy.

Carney complex is a rare autosomal dominant disorder characterized by multiple tumors, including cardiac and extracardiac myxomas, skin lesions, and various endocrine disorders. We are reporting a 21-year-old female patient with past surgical history significant for excision of a cutaneous myxoma who presented with multicentric cardiac myxomas involving the four cardiac chambers. She also presented with endocrinal disorders in the form of an enlarged right lobe of the thyroid, hyperthyroid state, and an incidentally noted adrenal cyst; hence, she was diagnosed with carney complex syndrome.

A case report of Löffler endocarditis in idiopathic hypereosinophilic syndrome: recovery is possible.

INTRODUCTION: Hypereosinophilic syndrome (HES) is a myeloproliferative disorder characterized by persistent eosinophilia that is associated with damage to multiple organs. CASE PRESENTATION: Herein, we describe a case of left ventricular (LV) Löffler endocarditis on top of idiopathic HES leading to inflow and outflow obstruction. The posterior mitral leaflet was involved in the fibrotic process leading to severe mitral valve regurgitation. There was a mural thrombus in the left ventricle, which resulted in thrombo-embolic complications in the form of lower limb ischaemia. The patient was treated with high-dose corticosteroids and anticoagulants with significant improvement of his cardiac condition. DISCUSSION: In patients with persistent hypereosinophilia, thorough workup is recommended to identify any possible primary cause and detect associated end-organ damage. Treatment should be started as early as possible after establishing the diagnosis to reduce morbidity and prevent complications. Corticosteroids are the first-line therapy that usually cause a rapid reduction in the level of the eosinophilia and must be started promptly if cardiac involvement is present to attain rapid reduction in the eosinophil level and reverse the cardiac damage.