[Infective endocarditis and specific situations: Right heart, valve prosthesis, cardiac implantable electronic device]. / Endocardites infectieuses : formes particulières (coeur droit, prothèse valvulaire, dispositif électronique intracardiaque).

Right-sided infective endocarditis (IE) represents 5-10% of IE. It may occur in patients with electronic intracardiac device, central venous catheter or congenital heart disease, but the most frequent situation is intravenous drug use. Prosthetic valve IE is the most severe form of IE. The diagnosis is more challenging than that of native valve IE, as is treatment, both antibiotic treatment and surgical indications. The infection of an electronic intracardiac device is a severe disease. Both diagnostic and therapeutic strategies are difficult.

[Diagnosis of infective endocarditis]. / Diagnostic de l'endocardite infectieuse.

Clinical presentations cliniques of infective endocarditis are highly diverse. The diagnosis is often difficult. The two key investigations are blood cultures and echocardiography.

Systematic Search for Present and Potential Portals of Entry for Infective Endocarditis.

BACKGROUND: Looking for and treating the portal of entry (POE) of infective endocarditis (IE) is important, but published research on this topic is nonexistent. OBJECTIVES: The goal of this study was to systematically search for the POEs of present and potentially new episodes of IEs. METHODS: Patients were systematically seen by a stomatologist, an ear, nose, and throat specialist, and a urologist; women were systematically seen by a gynecologist; patients were seen by a dermatologist when there were cutaneous and/or mucous lesions. Colonoscopy and gastroscopy were performed if the microorganism came from the gastrointestinal tract in patients ≥50 years of age and in those with familial histories of colonic polyposis. Treatment of the POE was systematically considered. RESULTS: The POEs of the present IE episodes were identified in 74% of the 318 included patients. The most frequent POE was cutaneous (40% of identified POEs). It was mainly (62% of cutaneous POEs) associated with health care and with intravenous drug use. The second most frequent POE was oral or dental (29%). A dental infectious focus was more often involved (59% of oral or dental POEs) than a dental procedure (12%). POEs were gastrointestinal in 23% of patients. Colonic polyps were found in one-half of the patients and colorectal adenocarcinomas in 14%. Performance was good regarding the search for an oral or dental or a colonic potential POE, which were found in 53% and 40% of patients, respectively. CONCLUSIONS: Our search for the POEs of present IEs was often successful, as was searching for an oral or dental or a gastrointestinal POE of a new IE episode. We advise the systematic performance of stomatologic examinations in patients with IE and performance of colonoscopy in patients ≥50 years of age or at high risk for colorectal cancer.

Optimal timing for cardiac surgery in infective endocarditis: is earlier better?

All patients with infective endocarditis should be transferred to a hospital with cardiac surgery facilities. Once the decision to operate on a patient with infective endocarditis has been made, the timing of surgery is very often a difficult decision. Literature on this topic is very scarce. The European Society of Cardiology guidelines include recommendations on the timing of surgery. Heart failure, uncontrolled infection and prevention of embolic risk are the three main indications for surgery. Most often, when the decision to operate has been made, there is no benefit and potentially harm in delaying surgery. If cardiac surgery is indicated after an ischemic stroke, it should not be delayed. Discussion should be multidisciplinary and involve at least a cardiologist, a cardiac surgeon and an infectious diseases specialist, and any other specialist as needed (for example a neurologist).

Aortic valve stenosis after previous coronary bypass: transcatheter valve implantation or aortic valve replacement?

We report a prospective comparison between transcatheter valve implantation (TAVI, n = 13) and surgical aortic valve replacement (AVR, n = 10) in patients with severe aortic valve stenosis and previous coronary bypass surgery (CABG). All patients had at least bilateral patent internal thoracic arteries bypass without indication of repeat revascularization. After a similar post-procedure outcome, despite one early death in TAVI group, the 1-year survival was 100% in surgical group and in transfemoral TAVI group, and 73% in transapical TAVI group. When previous CABG is the lone surgical risk factor, indications for a TAVI procedure have to be cautious, specially if transfemoral approach is not possible.

Recommendations on prophylaxis for infective endocarditis: dramatic changes over the past seven years.

Recommendations on antibiotic prophylaxis against infective endocarditis have changed dramatically since 2002. In 2002, the French were the first to make a profound change: they proposed that antibiotic prophylaxis should be optional when a medical, surgical or dental procedure that carries a risk of infective endocarditis was performed in a patient at risk but not at very high risk of infective endocarditis (group B: native valve disease, non-cyanotic congenital heart disease, obstructive hypertrophic cardiomyopathy). In 2004, the European Society of Cardiology and the British Society of Cardiology made almost no changes to their previous recommendations. In 2006, the British Society for Antimicrobial Chemotherapy made another radical change: no antibiotic prophylaxis in group B patients. In 2007, the American Heart Association went a step further: no antibiotic prophylaxis before a gastrointestinal or genitourinary procedure in group A patients (valvular prosthesis, cyanotic congenital heart disease, history of infective endocarditis). In 2008, the British National Institute for Health and Clinical Excellence adopted an extreme position: no antibiotic prophylaxis at all in patients at risk for infective endocarditis.

[Infective endocarditis]. / Endocardite infectieuse.

Infective endocarditis is a severe disease. This fact justifies prophylaxis, although its indications have been narrowed over the last years; as early the diagnosis as possible, that forbids any antibiotic treatment without previous blood cultures in a patient with a cardiac disease at risk for infective endocarditis; often cardiac surgery, whose indications remain difficult and need the collaboration of the cardiologist, the infectious diseases specialist and the cardiac surgeon.

150 microgram intracoronary adenosine bolus for accurate fractional flow reserve assessment of angiographically intermediate coronary stenosis.

AIMS: Fractional flow reserve measurement is based upon achieving maximum hyperemia. A 40 microg intracoronary (IC) adenosine bolus sometimes seems insufficient, and we therefore sought to assess the possible role of 100-150 microg boli in routine. METHODS AND RESULTS: 108 intermediate (49+/-16%) stenoses were consecutively studied with 6F catheters. A history of myocardial infarction in the territory of the explored artery or myocardial hypertrophy were the exclusion criteria. Mean FFR was 0.82+/-0.12 with a 40 microg adenosine bolus and decreased to 0.80+/-0.12 and 0.80+/-13 respectively with 100microg and 150 microg boli (P<0.001 vs 40microg in both cases; 100 vs 150 microg, NS). The 40 microg bolus failed to diagnose 8 out of 30 (27%) significant stenoses (i.e., final FFR <0.75). The large boli led to 12 (11%) transient asymptomatic and spontaneously resolving AV blocks without other side-effects. CONCLUSION: FFR underestimated a quarter of intermediate stenoses with the currently used 40microg IC adenosine bolus. A large bolus up to 150 microg appears to be accurate and safe for routine FFR measurement.

[Epidemiology of acute coronary syndrome]. / Epidémiologie des syndromes coronaires aigus.

As for myocardial infarction, the epidemiology of acute coronary syndromes is very different according to whether it concerns hospitalized patients only or acute coronary syndromes as a whole: many patients die before any medical intervention. The epidemiology of acute coronary syndromes is not well known since we have almost no specific data regarding unstable angina. The annual incidence of acute coronary syndromes in France is greater than 280 per 100,000 men and 60 per 100,000 women. The 1-month lethality rate is about 50%, increasing sharply with age.

Limits of arterial myocardial revascularization.

A prospective study of myocardial blood perfusion after coronary artery bypass graft (CABG) was conducted in two groups of patients. In group 1, a two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients who consecutively underwent CABG with exclusive use of both internal mammary arteries (IMA) and gastroepiploic artery (GEA). In group 2, myocardial function and perfusion were determined by radionuclide investigations performed before and one year after CABG in 100 patients with preoperative LV dysfunction (defined as LV ejection fraction (LVEF) less than 0.40), comparing results of myocardial revascularization performed with either exclusive arterial grafts (arterial group, 54 patients) or one arterial graft (IMA) associated with a sequential vein graft (vein group, 46 patients). In group 1, 21% of patients presented silent residual electric ischemia during exercise stress testing and 26% had reversible scintigraphic ischemic defect despite complete revascularization, 18% of those in the inferior wall bypassed with GEA and 8% in the anterior wall bypassed with the right IMA. In group 2, the significant preoperative ischemia significantly decreased in both the vein group and the arterial group. LV function was significantly improved in the vein group; in contrast there was no modification of LV function in the arterial group. A multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial outcome, with a positive impact of the vein use on the postoperative myocardial function recovery. It is important to recognize that arterial grafts have some limitations in the ability to supply blood flow for coronary circulation that may induce postoperatively silent residual myocardial ischemia and a lack of LV function recovery.

Is coronary angiography performed in the appropriate patients after acute myocardial infarction? Clinical and angiographic findings and one-year mortality in a large unselected cohort of 2493 consecutive patients in a French region (the PRIMA study).

OBJECTIVE: Rates of coronary angiography (CA) after myocardial infarction (MI) vary widely between institutions. Furthermore, the indications for CA are often in conflict with recognized guidelines. The present study sought to determine the characteristics and the one-year mortality in patients with MI, regardless of age and hospital facilities, according to the use of CA after MI. METHODS AND RESULTS: Data were prospectively collected in all patients with MI admitted to all hospitals in three departments in the Rhône-Alpes region. Among 2493 patients, 1117 (45%) underwent CA. In multivariate analysis, CA rate was lower with increasing age, female sex, in patients with comorbidity or heart failure. CA was performed in 49% of patients admitted to hospitals with on-site CA vs. 32% in hospitals without on-site CA (OR: 3.54, after adjustment for patients' characteristics). One-year mortality rate was 6.5% for the CA group and 36.9% for the no-CA group. In multivariate analysis, age, history of angina pectoris, presence of Q waves, Killip class at admission II, III, or IV and CPK ratio > or = 9 were significant predictors of a higher one-year mortality, but performance of CA did not significantly influence it: RR: 0.79 (95% CI 0.58 to 1.07). CONCLUSIONS: Among patients with MI in a large unselected cohort in a French region, the one-year mortality was significantly lower in those referred for angiography. However, after correction for the confounding effects of simple baseline clinical indicators of risk, this apparent benefit reflected the fact that angiography was performed in those at lowest risk.

Do differences in baseline characteristics or in management account for the poorer in-hospital and subsequent outcome after myocardial infarction in diabetics? Data from a large unselected cohort.

OBJECTIVE: There is an excess mortality after myocardial infarction in diabetics, but also documented significant differences in the characteristics of MI and in management between diabetics and non-diabetics. The aim of this prospective study in a large unselected patient cohort in a single French region was to determine if baseline characteristics, management, or in-hospital and one-year mortality differed in diabetic and non-diabetic patients with myocardial infarction. METHODS AND RESULTS: Data were prospectively collected in consecutive patients with myocardial infarction admitted to all hospitals in three departments in the Rhone-Alpes region between September 1, 1993 and January 31,1995. Among the 2,297 patients, 410 patients (17.8%) were diabetic. Although diabetics were older than non-diabetics (70.3 vs. 67.8 years; p < 0.0004), and less likely to receive thrombolysis (31% vs. 36%; p = 0.043), in-hospital mortality was not significantly higher (17.3% vs. 14.7%) than in non-diabetics. In multivariate analysis, diabetes was a significant predictor of one-year mortality (relative risk: 1.41; 95% CI = 1.10 - 1.79; p = 0.0063) but not of in-hospital mortality (relative risk: 1.2; 95% CI = 0.9 - 1.7; p = 0.25). Multivariate predictors of in-hospital and one-year mortality in diabetics were age and Killip class at admission. CONCLUSIONS: In this large unselected French cohort, diabetes mellitus was a significant predictor of one-year but not of in-hospital mortality after myocardial infarction in a French region. This negative effect of diabetes on mortality was not related to differences in baseline characteristics, or in initial or post-discharge management between diabetics and non-diabetics.

Treatment and prevention of infective endocarditis.

The paper presents the most recent recommendations for the treatment and prevention of infective endocarditis (IE). The treatment of IE is complex and requires close collaboration among specialists in infectious diseases, cardiology, cardiac surgery and microbiology. The mainstay of medical treatment is antibiotic therapy. Theoretical considerations regarding vegetations and antibiotics have practical consequences on the route and modalities of administration of antibiotics and on the techniques used to monitor treatment. The choice of antibiotics depends on the microorganism (streptococci, enterococci, staphylococci, HACEK group [Haemophilus sp., Actinobacillus sp., Cardiobacterium sp., Eikenella sp. and Kingella sp.], Coxiella, Brucella, Legionella, Bartonella, fungi) and on whether IE occurs on native or prosthetic valves. Treatment of IE with negative blood cultures is particularly difficult. Cardiac surgery is often needed during the bacteriologically active period (in ~50% of patients). The decision to intervene and the optimal timing of the intervention requires careful consideration of multiple potential risks: the haemodynamic risk, the infectious risk, the risk due to cardiac lesions, the risk due to extracardiac complications and the risk due to the location of infective endocarditis. Even though the efficacy of antibiotic prophylaxis of IE is not completely proven, it is recommended for selected patients who undergo an at-risk procedure. Lists of cardiac conditions and of medical procedures at risk are presented; specific antibiotic prophylactic regimens for dental and upper respiratory tract procedures in out-patients, procedures under general anaesthesia and urological and GI procedures are outlined.