Diagnostic performance of contemporary transesophageal echocardiography with modern imaging for infective endocarditis.

Background: Infective endocarditis (IE) is associated with high morbidity and mortality. Following an initial negative transesophageal echocardiogram (TEE), high clinical suspicion warrants repeat examination. We evaluated the diagnostic performance of contemporary TEE imaging for IE. Methods: This retrospective cohort study included patients ≥18 years old undergoing ≥2 TEEs within 6 months, with confirmed diagnosis of IE based on Duke criteria, 70 in 2011 and 172 in 2019, were included. We compared the diagnostic performance of TEE for IE in 2019 versus 2011. The primary endpoint was the sensitivity of initial TEE to detect IE. Results: Sensitivity of the initial TEE to detect endocarditis was 85.7% versus 95.3%, in 2011 and 2019, respectively (P=0.01). On multivariable analysis, initial TEE more frequently detected IE in 2019, compared to 2011 [odds ratio (OR): 4.06, 95% confidence intervals (CIs): 1.41-11.71, P=0.01]. Improved diagnostic performance was driven by improved detection of prosthetic valve infective endocarditis (PVIE), sensitivity 70.8% in 2011 versus 93.7% (P=0.009) in 2019. In 2019, TEEs more frequently utilized probes with higher frame rates/resolution, than 2011 (P<0.001). Three dimensional (3D) technology was utilized in 97.2% of initial TEEs in 2019, compared to 70.5% in 2011 (P<0.001). Conclusions: Contemporary TEE was associated with improved diagnostic performance for endocarditis, driven by improved sensitivity for PVIE.

Outcomes of Interventional Management of Coronary Artery Disease in Kidney Transplant Recipients.

BACKGROUND: Cardiovascular disease is the most common cause of death among kidney transplant (KT) recipients. Trials routinely exclude patients with end-stage renal disease when assessing the effect of coronary artery revascularization. We looked to compare long-term outcomes in patients who underwent percutaneous coronary intervention (PCI) before KT with those managed medically. METHODS: We identified all patients who underwent coronary artery catheterization before KT from January 2008 to November 2019 at the Cleveland Clinic. The primary endpoint was all-cause mortality. RESULTS: A total of 272 patients were included, of whom 52 (19.11%) underwent PCI, and the remaining 220 patients were managed medically. The median age in the PCI group was 57.4 years (interquartile range [IQR], 46.9-61.2 years), whereas it was 53.9 years (IQR, 44.6-61 years) in the group medically managed. Baseline characteristics including sex, race, hypertension, diabetes, smoking, and hyperlipidemia were comparable in both groups. The median time to KT was 2.4 years (IQR, 1-5 years) in the PCI group vs 1.2 years (IQR, 0.6-3.3 years) in the medically managed group (P = .001). Among patients who underwent PCI, 40.4% had single vessel disease and 59.6% had multivessel disease compared with 16.8% and 28.6%, respectively, in the medically managed group (P < .001). Overall, there was no difference in mortality in the PCI group compared with the medically managed group after 10 years of follow-up (P = .416). CONCLUSIONS: Patients with coronary artery disease can be safely treated with PCI before KT and have comparable outcomes to those who are managed medically.

Intra-operative uterine artery embolization with caesarean delivery in an adjoining operating theatre and catheter lab (OT/CL) complex vs. conventional management in patients with abnormally invasive placenta: a retrospective case control study.

Patients of abnormally invasive placenta (AIP) undergoing caesarean delivery are at increased risk of haemorrhage. Conventional management includes piecemeal removal of placenta or placenta left in situ. However, they often require hysterectomy after delivery. Post-delivery prophylactic uterine artery embolisation (UAE) can help reduce morbidity and preserve fertility. We created an adjoining operating theatre and catheter lab (OT/CL complex). This is a retrospective case control study in which 37 patients of AIP were evaluated. Sixteen subjects (cases) had UAE immediately after caesarean delivery, and 21 subjects (controls) had usual care with traditional methods of controlling postpartum haemorrhage and hysterectomy where required. The hysterectomy rate (18.7% vs. 85.7%), mean duration of hospital stay (6.8 ± 2.6 vs. 13.9 ± 8.1) and number of units of blood transfusion required were significantly less in the case group as compared with controls. UAE is an effective conservative treatment along with caesarean delivery in patients with AIP.Impact statementWhat is already known? AIP is associated with high rates of PPH, maternal morbidity and mortality and need for hysterectomy after delivery. UAE has been advocated to preserve fertility and reduce PPH in these patients along with caesarean delivery.What does the study add? We created an adjoining operating theatre and catheter lab (OT/CL complex) in a tertiary care centre and managed these patients with prompt UAE after caesarean delivery with team approach. We have shown significant reduction in morbidity and hospital stay with this coordinated management.What are the implications for clinical practice and/or further research? UAE with caesarean delivery is a preferred mode of delivery for patients of AIP. These patients should be diagnosed and referred to tertiary care centres with such facilities electively so as to provide optimal care to these patients. Cooperation between interventionist and obstetrician and adjoining availability of OT and catheter lab can further help in reducing the time to embolisation after delivery. A hybrid operating theatre with digital subtraction angiography (DSA) facilities would be ideal for the management of such patients.