Recurrence of syncope after valve replacement in severe aortic stenosis.

OBJECTIVE: The recurrence of syncope after valve intervention in severe aortic stenosis (SAS) and its impact on outcome are unknown. We hypothesised that syncope on exertion will disappear after intervention, whereas syncope at rest might recur. Our aim has been to describe the recurrence of syncope in patients with SAS undergoing valve replacement and its impact on mortality. METHODS: Double-centre observational registry of 320 consecutive patients with symptomatic SAS without other valve disease and/or coronary artery disease who underwent valve intervention and were discharged alive. All-cause mortality and cardiovascular mortality were considered events. RESULTS: 53 patients (median age 81 years, 28 men) had syncope (29 on exertion, 21 at rest, 3 unknown). Clinical and echocardiographic variables were similar in patients with and without syncope (median vmax 4.44 m/s, mean gradient 47 mm Hg, valve area 0.7 cm2, left ventricular ejection fraction 62%). After a median follow-up of 69 months (IQR: 55-88), syncope on exertion did not recur in any patient. In contrast, 8 of the 21 patients with syncope at rest had postintervention syncope at rest (38%; p<0.001): 3 needed a pacemaker, 3 were neuromediated or hypotensive and 2 arrhythmic. Only recurrence of syncope was associated with cardiovascular mortality (HR 5.74; 95% CI 2.17 to 15.17; p<0.001). CONCLUSIONS: Syncope on exertion in patients with SAS did not recur after aortic valve intervention. Syncope at rest recurs in a high proportion of patients and identifies a population with increased mortality. According to our results, syncope at rest should be thoroughly evaluated before proceeding to aortic valve intervention.

Impact of intra-abdominal pressure on early kidney transplant outcomes.

Increased intra-abdominal pressure (IAP) is common among post-surgical patients and may cause organ dysfunction. However, its impact after kidney transplantation on early postoperative complications and graft recovery remains unclear. We designed a prospective, observational cohort study to describe the prevalence and determinants of IAP, as well as its effect on delayed graft function, postoperative complications, and graft recovery. IAP was measured in 205 kidney transplant recipients every 8 h during the first 72 h after surgery using the urinary bladder technique. Intra-abdominal hypertension was defined as IAP ≥ 12 mmHg. Patients were followed for 6 months or until graft failure/death. Mean IAP was 12 ± 3.3 mmHg within the first 24 h. 78% of subjects presented with intra-abdominal hypertension during the first 72 h. Increased IAP was associated with higher renal resistive index [r = 0.213; P = 0.003] and lower urine output [r = - 0.237; P < 0.001]. 72 h mean IAP was an independent risk factor for delayed graft function [OR: 1.31; 95% CI: 1.13-1.51], postoperative complications [OR: 1.17; 95% CI: 1.03-1.33], and absence of graft function recovery [HR for graft function recovery: 0.94; 95% CI: 0.88-0.99]. Increased IAP was highly prevalent after transplantation and was independently associated with delayed graft function, postoperative complications, and absence of graft function recovery. Routine IAP monitoring should be considered post-transplantation to facilitate early recognition of relevant complications.

Age-dependent profile of left-sided infective endocarditis: a 3-center experience.

BACKGROUND: The influence of age on the main epidemiological, clinical, echocardiographic, microbiological, and prognostic features of patients with infective endocarditis remains unknown. We present the series with the largest numbers and range of ages of subjects to date that analyzes the influence of age on the main characteristics of patients with isolated left-sided infective endocarditis. Furthermore, this series is the first one in which patients have been distributed according to age quartile. METHODS AND RESULTS: A total of 600 episodes of left-sided endocarditis consecutively diagnosed in 3 tertiary centers were stratified into age-specific quartiles and 107 variables compared between the different groups. With increasing age, the percentage of women, previous heart disease, predisposing disease (diabetes mellitus and cancer), and infection by enterococci and Streptococcus bovis also increased. Valvular insufficiency and perforation and Staphylococcus aureus infection were more common in younger patients. The therapeutic approach differed depending on patient age because of the growing proportion of older patients who only received medical treatment. Clinical course and hospital prognosis were worse in the older patients because of increased surgical mortality among them. CONCLUSIONS: Increasing age is associated with less valvular impairment (insufficiency and perforation), a more favorable microbiological profile, and increased surgical mortality among adults with left-sided infective endocarditis.

Characteristics and Outcomes of Patients Hospitalized With Suspected Acute Coronary Syndrome in Whom the Diagnosis is not Confirmed.

Patients admitted with suspected acute coronary syndrome (ACS) in whom the diagnosis is not confirmed are poorly characterized. In a contemporary registry of consecutive patients hospitalized with suspected ACS as the primary diagnosis, we assessed characteristics on admission and in-hospital and 6-month mortality of patients discharged with other diagnoses and compared this subgroup with true ACS patients. Of 2557 patients included, 9.0% were discharged with a non-ACS diagnosis such as nonspecific chest pain, myopericarditis, stress cardiomyopathy, hemodynamic disturbances, heart failure, myocardial, pulmonary or valvular disease, or others. Compared with true ACS patients, those with other diagnoses were younger, more often female, and had less cardiovascular risk factors. Both groups had comparable rates of nonchest pain presentation and similar hemodynamic characteristics on admission. Non-ACS patients presented less often with Q waves or with ST-segment or T-wave changes and had a lower Global Registry of Acute Coronary Events score than true ACS patients. In-hospital (4.3 vs 4.0%, respectively, p = 0.834) and 6-month (5.4 vs 8.0%, respectively, p = 0.163) mortality rates were comparable in both groups. However, if patients in the non-ACS group were divided into subgroups with nonspecific chest pain (6.2% of total) or other diagnoses (2.8% of total), major differences in in-hospital (0.0 vs 13.9%, respectively, p < 0.001) and 6-month (0.7 vs 15.7%, respectively, p < 0.001) mortality rates would become apparent and remain after multivariable adjustment. In conclusion, in a non-negligible proportion of patients hospitalized with suspected ACS, this diagnosis is not confirmed. Prognosis of these patients follows a bimodal pattern, being excellent in those with nonspecific chest pain but worse than that of true ACS patients in the rest. Efforts are necessary to ensure prompt identification and early risk stratification of these patients allowing appropriate management decisions.

Comparison of Different Bone Marrow-Derived Stem Cell Approaches in Reperfused STEMI. A Multicenter, Prospective, Randomized, Open-Labeled TECAM Trial.

BACKGROUND: Stem cell-based therapy has emerged as a potential therapy in acute myocardial infarction (AMI). Although various approaches have been studied, intracoronary injection of bone marrow autologous mononuclear cells (BMMC) and the ability of granulocyte colony-stimulating factor (G-CSF) to mobilize endogenous cells have attracted the most attention. OBJECTIVES: This study compares, for the first time, the efficacy of BMMC injection, G-CSF mobilization, and the combination of both with standard treatment. METHODS: On Day 1 after primary percutaneous coronary intervention, 120 patients were randomized to a 1) intracoronary BMMC injection; 2) mobilization with G-CSF; 3) both (BMMC injection plus G-CSF); or 4) conventional treatment (control group). G-CSF, 10 µg/kg/day subcutaneously, was started Day 1 and maintained for 5 days. BMMC injection was performed on Days 3 to 5. Our primary endpoint was absolute change in 12-month left ventricular ejection fraction (LVEF) and left ventricular end-systolic volume (LVESV) relative to baseline measured by cardiac magnetic resonance. RESULTS: The mean change in LVEF between baseline and follow-up for all patients was 4 ± 6% (p = 0.006). Change in LVEF and LVESV over time did not differ significantly among the 4 groups. Patients actively treated with any stem cell approach showed similar changes in LVEF and LVESV versus control subjects, with a small but significant reduction in infarct area (p = 0.038). CONCLUSIONS: In our study, 3 different bone marrow-derived stem cell approaches in AMI did not result in improvement of LVEF or volumes compared with standard AMI care (Trial of Hematopoietic Stem Cells in Acute Myocardial Infarction [TECAM]; NCT00984178).

Clinical profile of Streptococcus agalactiae native valve endocarditis.

BACKGROUND: Streptococcus agalactiae is an unusual pathogen in adults who are not pregnant. S agalactiae endocarditis is a poorly defined entity because it is uncommon; in contrast to other streptococcal endocarditis, it bears a high mortality rate. The aim of this study was to define its clinical, prognostic, and therapeutic profile on the basis of a series of 9 consecutive patients. METHODS: We conducted a prospective and multicenter study of patients with infectious endocarditis in which 310 episodes were included. RESULTS: S agalactiae grew in 9 patients (3%) who had no valve prosthesis. All patients except 1 had underlying diseases, and all patients had serious complications; the most common complications were major emboli, heart failure, and shock. The valve affected was the mitral valve in 4 patients, the aortic valve in 2 patients, both the mitral and aortic valves in 2 patients, and the tricuspid valve in 1 patient. All episodes were on native valves. Vegetations tended to be large (maximal diameter >10 mm in all patients), very mobile, and pedunculated. An abscess was found in 2 patients, and a perforation of the valve developed in 3 patients. Five patients died (mortality rate, 56%), 3 of whom had received antibiotic therapy alone. The 4 patients who survived underwent combined medical-surgical therapy. CONCLUSION: S agalactiae native valve endocarditis is very aggressive, and early surgery should be considered to prevent the destruction of valves and development of serious complications.

Dobutamine stress echocardiography in the diagnosis of coronary artery disease in women with chest pain: comparison with different noninvasive tests.

BACKGROUND: Diagnosis of coronary artery disease(CAD) in women remains elusive. The classical diagnostic armamentarium has been found to be very limited. Dobutamine stress echocardiography has emerged as a powerful test in assessing CAD in the general population, but most studies failed to include women. HYPOTHESIS: The accuracy of dobutamine stress echocardiography in the diagnosis of CAD in women with chest pain is high and superior to dipyridamole echocardiography, exercise electrocardiography, and sestamibi single-photon emission tomography (MIBI-SPECT) scintigraphy. METHODS: We studied 99 consecutive women with chest pain and no previous history of CAD who underwent dobutamine echocardiography and coronary angiography. We also compared these results with those of dipyridamole echocardiography in 63 patients. exercise stress testing in 83 (48 conclusive), and MIBI-SPECT scintigraphy during dobutamine infusion in 54. RESULTS: Significant CAD was found in 42 women. Sensitivity and specificity of dobutamine stress echocardiography were 69 and 89%, respectively. Dipyridamole echocardiography showed similar accuracy (sensitivity 72% and specificity 94%). Finally, sensitivity of exercise test and MIBI-SPECT was similar (76 and 88%, respectively) and specificity was lower (53 and 57%, respectively). After excluding patients known to have a high incidence of false positive results, MIBI-SPECT specificity rose up to 80%. CONCLUSION: Dobutamine stress echocardiography and dipyridamole echocardiography bear a high diagnostic accuracy in women with chest pain. MIBI-SPECT is also a useful tool after excluding subgroups with a high incidence of false positive results.

Desarrollo de un instrumento para la evaluación del malestar emocional para pacientes renales en diálisis / Development of a questionnaire to assess emotional distress in renal patients undergoing dialysis

Objetivo: Actualmente no existen herramientas validadas para evaluar el malestar emocional en pacientes con enfermedad renal crónica, pese a su alta prevalencia en todas las etapas de la patología. Este trabajo describe el desarrollo de un instrumento breve semiestructurado para la Evaluación del malestar Emocional de los pacientes renales en Diálisis (EE-D). Método: El EE-D incluye cinco preguntas con distintos formatos de respuesta (dicotómico, Likert y preguntas abiertas) para evaluar tristeza, ansiedad, preocupaciones, recursos para afrontar la enfermedad, signos externos de malestar y observaciones. Los ítems de la primera versión se sometieron a un estudio interjueces (N= 10). Posteriormente se realizó un estudio piloto multicéntrico (N= 25 pacientes en 5 hospitales). Resultados: Tras el estudio interjueces un ítem fue eliminado, y otro añadido. Tras el piloto no hubo modificaciones. La puntuación media (sobre 10) fue 4,16 (DT: 3,41) en tristeza y 3,68 (DT: 3,48) en ansiedad. El 48% refirió preocupaciones familiares, el 44% preocupaciones sobre su estado emocional-psicológico y el 40% sobre su enfermedad/tratamientos. Los principales recursos identificados fueron la esperanza en la posibilidad de trasplante y el apoyo social. A juicio de enfermería el 24% presentan expresión facial de malestar y el 16% otros signos de malestar. Discusión: El EE-D muestra unas garantías psicométricas preliminares. Ha sido distribuido en las Unidades de Diálisis de todo el territorio nacional con el objetivo de su implementación clínica en un marco investigador, lo que permitirá el desarrollo de futuros estudios de validación multicéntricos (AU)

Objective: Currently there are no validated assessment tools to explore emotional distress in patients with chronic kidney disease, even though it is very prevalent in all the phases of the disease. This study describes the development of a brief semi-structured interview to assess emotional distress in renal patients undergoing Dialysis (EE-D). Method: The EE-D includes five questions with different response formats (dichotomized, Likert scales and open-questions) to assess sadness, anxiety, concerns, and resources to cope with illness, external signs of distress and other considerations. An interjudge process was used with the items of the first version of the EE-D (N= 10 experts). Hereafter a pilot multicentric study was carried on (N= 25 patients in 5 hospitals). Results: After the interjudge analysis one item was removed from the EE-D, and one item was added. After the pilot study there were no changes in the tool. The average score (range 0 to 10) in sadness was 4.16 (SD= 3.41) and 3.68 (SD= 3.48) in depression. A total of 48% of the participants reported family concerns, 44% concerns about their psychological/ emotional state and 40% about their illness/treatments. The most important resources to cope with the illness were their hope in the possibility of a transplantation and their social support. According to the nursing staff who conducted the interviews 24% of the patients showed facial expression of distress and 16% other external signs of distress. Discussion: The EE-D has shown adequate preliminary psychometric properties. It has been recently distributed to all the dialysis units in Spain with the objective of conducting a multicentric validation study (AU)

Safety and predictors of complications with a new accelerated dobutamine stress echocardiography protocol.

BACKGROUND: This study sought to document the safety of a new accelerated dobutamine-atropine stress echocardiography protocol and to analyze its complications. METHODS: Dobutamine-atropine stress echocardiography studies were performed using an incremental dobutamine infusion protocol from 20 to 40 microg/kg/min in 3-minute stages and followed by atropine. RESULTS: A total of 962 patients were included. Mean age was 64 +/- 11 years and 584 were male (61%). Mean ejection fraction was 62 +/- 10%. Complications included hypertensive responses in 66 patients (7%), arrhythmias in 26 (2.7%), and symptomatic hypotension in 16 (1.7%). No patient developed heart failure, acute myocardial infarction, ventricular fibrillation, or died. The independent predictors of hypertensive responses were age, baseline systolic blood pressure, and treatment with nitrates. The independent predictors of arrhythmias were history of hypertension, previous coronary artery disease, and baseline heart rate. CONCLUSIONS: This accelerated dobutamine-atropine stress echocardiography protocol is safe in a low-risk population and has a rate of complications similar to that reported for the standard protocol.

Definition, clinical profile, microbiological spectrum, and prognostic factors of early-onset prosthetic valve endocarditis.

AIM: There is no agreement in the best cutoff time to distinguish between early- and late- onset prosthetic valve endocarditis (PVE). Our objectives are to define early-onset PVE according to the microbiological spectrum and to analyse the profile and short-term prognosis of this entity. METHODS AND RESULTS: The microbiological profile of 172 non-drug users, who were patients with PVE, were compared according to the time elapsed from surgery among 640 endocarditis diagnosed between 1996 and 2004. There were no differences in the microbiological profile of patients with PVE occurred within 2 months of valve replacement and those accounting between 2 and 12 months. The proportion of coagulase-negative Staphylococci (CNS) was higher during the first year post-intervention (37 vs. 18%, P = 0.005) and Streptococci viridans were more common after 1 year (18 vs. 1%, P = 0.001). The percentage of methicilin-resistant CNS strains was higher before 1 year (77 vs. 30%, P = 0.004). Early-onset PVE represented 38% of all episodes of PVE, CNS being the most frequent isolated microorganisms (37%), most of them methicilin resistant (77%). In-hospital mortality of patients who needed urgent surgery was 46% and elective surgery 25%. Overall, in-hospital mortality was 38% and no differences were seen between surgical and medical groups (32 vs. 45%, P = 0.30). Periannular complications were associated with higher in-hospital mortality (60 vs. 27%, P = 0.007). CONCLUSION: According to the microbiological profile, the most appropriate cutoff time to distinguish between early- and late-onset PVE was 1 year. Methicilin-resistant CNS are the most frequent pathogens and periannular complications, the only risk factor for in-hospital mortality.

Acute pulmonary edema secondary to myocardial damage after electrical cardioversion.

Direct cardioversion used in the treatment of various cardiac arrhythmias is a highly effective and simple procedure with infrequent complications. An uncommon complication is the occurrence of pulmonary edema. This report describes a 68-year-old woman with normal coronary arteries who experienced pulmonary edema following cardioversion secondary to myocardial injury demonstrated by ECG changes and elevation of troponin T.