Does nutritional intervention maintain its prognostic benefit in the long term for malnourished patients hospitalised for heart failure? / ¿Mantiene la intervención nutricional en pacientes hospitalizados por insuficiencia cardiaca desnutridos su beneficio pronóstico a largo plazo?

OBJECTIVE: To assess the long-term effect of nutritional intervention on malnourished, hospitalised patients with heart failure (HF). METHODS: A total of 120 malnourished patients hospitalized for HF were randomised to undergo (or not) an individual nutritional intervention for 6 months. The primary event was the combination of all-cause death and readmission for HF. We performed an intent-to-treat analysis and assessed the effect of the intervention at 24 months. RESULTS: The combined event occurred in 47.5% of the intervention group and in 73.8% of the control group (hazard ratio: 0.45; 95% confidence interval: 0.28-0.72; P=.001). Thirty-nine percent of the intervention group and 59% of the control group died (hazard ratio: 0.53; 95% confidence interval: 0.31-0.89; P=.017). CONCLUSION: A nutritional intervention for malnourished patients hospitalised for HF maintains its prognostic benefit in the long-term follow-up.

[Differential characteristics of primary acute pericarditis and severe pericardial effusion without tamponade]. / Características diferenciales de las pericarditis agudas primarias con derrame pericárdico severo sin taponamiento.

The aim or our study was to evaluate the main clinical and etiological features or primary acute pericarditis with severe pericardial effusion without cardiac tamponade. Our experience included 35 patients with this problem diagnosed in the last 5 years. Patients with a previous potential etiology for acute pericarditis were excluded. The diagnostic protocol identified a specific etiology in 20% of patients, the most frequent being idiopathic forms. Patients with severe pericardial effusion without cardiac tamponade who had a favourable clinical outcome on nonsteroidal antiinflammatory drugs therapy presented a lower proportion of specific etiology than those with a poor response to this therapy (8% versus 45%; p = 0.03). An exhaustive etiological investigation, including diagnostic pericardiocentesis should be reserved for these patients with unfavourable response to antiinflammatory drug therapy.

Características diferenciales de las pericarditis agudas primarias con derrame pericárdico severo sin taponamiento / Differential characteristics of primary acute pericarditis and severe pericardial effusion without tamponade

El objetivo de este trabajo es evaluar las principales características clínicas y etiológicas de las pericarditis agudas primarias que se inician con derrame severo sin taponamiento. Presentamos nuestra experiencia en 35 pacientes en los últimos 5 años. Todos los pacientes en los que hubiese una causa potencial de pericarditis en la primera valoración clínica fueron descartados. El protocolo diagnóstico encaminado a la búsqueda de una etiología específica ha obtenido un rendimiento global del 20%, siendo, por tanto, las formas idiopáticas las más frecuentes. Los casos con derrame severo y respuesta favorable al tratamiento presentaron menor proporción de etiologías específicas que los que no respondieron al tratamiento con antiinflamatorios no esteroideos (el 8% frente al 45%; p = 0,03). Es, por tanto,en estos últimos en los que se justificaría una investigación etiológica exhaustiva, incluyendo una pericardiocentesis diagnóstica dada la mayor probabilidad de hallar una causa específica de la enfermedad

The aim or our study was to evaluate the main clinical and etiological features or primary acute pericarditis with severe pericardial effusion without cardiac tamponade. Our experience included 35 patients with this problem diagnosed in the last 5 years. Patients with a previous potential etiology for acute pericarditis were excluded. The diagnostic protocol identified a specific etiology in 20% of patients, the most frequent being idiopathic forms. Patients with severe pericardial effusion without cardiac tamponade who had a favourable clinical outcome on nonsteroidal antiinflammatory drugs therapy presented a lower proportion of specific etiology than those with a poor response to this therapy (8% versus 45%; p = 0.03). An exhaustive etiological investigation, including diagnostic pericardiocentesis should be reserved for these patients with unfavourable response to antiinflammatory drug therapy

[Clinical features and prognosis of infective endocarditis in the elderly]. / Características clínicas y pronósticas de la endocarditis infecciosa en el anciano.

INTRODUCTION AND OBJECTIVES: In recent decades the mean age of patients with infective endocarditis has progressively increased. The objective of the present study was to describe the clinical features and prognoses of infective endocarditis in the elderly. METHODS: A prospective study was performed of 125 non drug abuser patients over the age of 14 years and admitted from 1987 until 1997 in a single institution. Twenty-one patients were older than 65 years. RESULTS: No significant differences were observed among the age groups with respect to delay in diagnosis, clinical signs, site of the infection and the rate of negative blood cultures. Prosthetic valve endocarditis was more frequent in elderly than in younger adults (41 and 33%, respectively). S. viridans and enterococcus were more frequent (47 compared with 29% in younger adults, p < 0.05). Elderly patients underwent surgery less frequently (46 versus 56%) and most surgery was performed on an emergency basis. The in hospital mortality was higher in the elderly (50 versus 15%), p < 0.05. CONCLUSIONS: Prosthetic valve endocarditis and severe complications during the active phase are more frequent in the elderly and this is related to a worse prognosis in the short and intermediate term. A higher rate of elective surgery during the active phase could improve the prognosis of infective endocarditis in the elderly.

[Short and long-term prognosis of prosthetic valve endocarditis in non-drug addicts]. / Pronóstico a corto y largo plazo de la endocarditis sobre prótesis en pacientes no drogadictos.

INTRODUCTION AND OBJECTIVES: Prosthetic valve infective endocarditis is a complication of valvular replacement surgery with a high morbimortality during the in-hospital phase and an important risk of complications during follow-up. The objective of the present study is to assess the clinical features and the short and long-term prognosis of this disease. PATIENTS AND METHODS: A prospective study of 43 consecutive cases of prosthetic valve endocarditis in non-addict patients from January 1987 to March 1997. RESULTS: The mean age was 51 +/-16 years. Eight patients (19%) had early prosthetic valve endocarditis (two months following heart surgery), fourteen patients (32%) had intermediate (between 2 and 12 months post surgery) and twenty-one (49%) had late prosthetic valve endocarditis (more than one year after heart surgery). Transesophageal echocardiography was performed in 32 patients with a sensibility of 81%. Complications occurred in 86% of patients and 53% of patients underwent surgery during the active phase (25% was emergency surgery). Inpatient mortality was 23% (50% in early prosthetic valve endocarditis). After a mean follow-up of 56 months there were 5 cases of recurrence, four patients required late surgery and 5 patients died. Survival (excluding early mortality) was 82% at 5 years with no significant differences among patients who received only medical treatment and those who underwent surgery in the active phase. CONCLUSIONS: Early mortality of prosthetic valve endocarditis is, according to our experience of 20%. The prognosis of survivors to the active phase is favourable in the majority. Early prosthetic valve endocarditis still causes a high mortality rate despite the use of combined medical surgical treatment in most cases.

[Fungal endocarditis in non drug-addict patients. 10-year experience]. / Endocarditis por hongos en pacientes no adictos a drogas por vía parenteral. Nuestra experiencia en 10 años.

INTRODUCTION AND OBJECTIVES: Fungal endocarditis is an uncommon but serious disease. Five cases of fungal endocarditis, involving non-addict patients, were diagnosed at our hospital in the last 10 years. RESULTS: Causal organisms included Candida albicans (3 patients), Saccharomyces (1 patient) and Torulopsis glabrata (1 patient). The predisposing condition to fungal infection was previous cardiac surgery in four cases (three of them with prosthetic heart valves, and the other patient underwent total surgical correction of Tetralogy of Fallot). No predisposing cause was found in one patient. All patients developed important complications. Three cases underwent cardiac surgery that evolved favorably, and two patients had contraindications for surgery and died from multiorgan septic involvement (overall survival was 60%). CONCLUSIONS: The incidence of fungal endocarditis involving non-addict patients has represented 3% of all cases of infective endocarditis. Even nowadays, fungal endocarditis is a disease with a high mortality and a precocious diagnosis is important to approach surgical treatment and to improve its prognosis.

[The general characteristics and short- and long-term results of infective endocarditis in non-drug addicts]. / Características generales y resultados a corto y largo plazo de la endocarditis infecciosa en pacientes no drogadictos.

INTRODUCTION AND OBJECTIVES: Infective endocarditis is a disease with a high morbimortality during the active phase and a considerable risk of complications during follow-up. The aim of our study is to describe the clinical and prognostic features of infective endocarditis in non-drug addict patients in short and long terms. PATIENTS AND METHODS: A prospective study of 138 cases of infective endocarditis in non-drug addict patients through the parenteral pathway treated in our institution from 1987 to 1997. RESULTS: The mean age was 44 +/- 20 years. Ninety-five patients (69%) had native valve infective endocarditis and forty-three (31%) had prosthetic valve endocarditis. Streptococci were the causal microorganism in 34% and staphylococci in 33%. 83% of patients developed some type of complications during hospital stay. 51% of patients were operated on during the active phase (22% were urgent). The in-hospital mortality rate was 21%. 10 patients (9%) needed late cardiac surgery and seven patients (5%) died during follow-up. Global survival at 10 years was 71%. There were no statistical differences in survival in as much as the type of treatment received during the hospital stay in the active phase (medical alone or combined medical-surgical). CONCLUSIONS: A high early surgery rate in the active phase related to good long-term results and does not increase early in-hospital mortality. Medical treatment also offers good long-term results in cases of infectious endocarditis with absence of bad prognostic factors and good clinical outcome.

[Isolated left ventricular myxoma discovered incidentally by echocardiography]. / Mixoma ventricular izquierdo aislado descubierto casualmente por ecocardiografía.

We describe the case of a young patient in whom two-dimensional echocardiography, performed because of episodes of palpitations, discovered the presence of a small mass in the left ventricle, attached to the posterior wall. Transesophageal echocardiography was performed to further assess the mass's attachments and to verify the lack of involvement of the mitral valve and its associated structures. The patient had a cardiopulmonary bypass, surgery and the mass was removed approaching into the left ventricular cavity through the atrial septum via a right atriotomy, without any complication during the postoperative period. In the histologic study the mass appeared to be a typical myxoma. This case has a great interest because the ventricular location of the myxoma is unusual; and because the use of two-dimensional echocardiography, even in the absence of significant symptoms and/or signs, avoided dangerous embolic complications, which often represent the first sign of this neoplastic pathology.

[Aneurysm of the anterior mitral valve in a case of aortic endocarditis in a patient with ulcerative colitis]. / Aneurisma de la valva anterior mitral en un caso de endocarditis aórtica en un paciente diagnosticado de colitis ulcerosa.

We report a case of an aortic endocarditis caused by Enterococcus faecium in a 34 year old patient diagnosed with ulcerative colitis. A Doppler echocardiogram showed an anterior mitral valve leaflet aneurysm, which made surgery necessary. Mitral valve leaflet aneurysm is a rare, though well-known complication of aortic valve endocarditis which can eventually perforate.

[Abscess of the mitral-aortic confluence and perforation of the mitral valve in a patient with Brucella endocarditis]. / Absceso de la confluencia mitroaórtica y perforación de la válvula mitral en un paciente con endocarditis por Brucella.

We report a case of Brucella aortic valve endocarditis in a 36 year-old patient with no underlying heart disease who required urgent surgery. In the postoperative follow-up, he suffered from congestive heart failure due to an anterior mitral valve rupture. In the echocardiogram, a periprosthetic abscess was seen and a second intervention was necessary. This report suggests that treating Brucella endocarditis requires a combined medical and surgical approach.

[Austrian's syndrome (endocarditis, meningitis and pneumonia caused by Streptococcus pneumoniae). Apropos of a rare case]. / Síndrome de Austrian (endocarditis, meningitis y neumonía por Streptococcus pneumoniae). A propósito de un caso poco frecuente.

We report a case of a mitral endocarditis caused by Streptococcus pneumoniae in a 48 year old man diagnosed with moderate mitral stenosis and liver cirrhosis. The clinical features were fever with penicillin-sensitive pneumococcal bacteremia, meningitis and pneumonia. Only transesophageal echocardiography could confirm the presence of vegetations. In spite of vancomycin therapy, the patient required mitral valve replacement, with good results. Some clinical aspects of this uncommon cause of infective endocarditis are discussed.