The clinical value of the endocarditis team: insights from before and after guidelines implementation strategy.

PURPOSE: To evaluate the impact of a multidisciplinary the "Endocarditis Team" (ET) on the course and outcome of infective endocarditis (IE) patients. METHODS: A retrospective before-after study, including hospitalized patients with definite IE, managed before (01.2013-12.2015) and after (01.2016-07.2019) the introduction of an ET. The primary outcomes were defined as 30-day and 1-year mortality and the secondary as conservative vs. invasive strategy, the interval from clinical suspicion of IE to the performance of echocardiography, utilization of multimodality evaluation, time to an invasive procedure, and the duration of hospitalization. RESULTS: Study population included 92 pre-ET and 128 post-ET implementation patients. Baseline characteristics were similar. During the post-ET period compared with pre-ET, we found higher rates of abscesses and extra-cardiac emboli (27.8% vs. 16.3%, p = 0.048); and a higher invasive procedures rate, including lead extraction (15.6% vs. 6.5%, p = 0.035) and noncardiac surgeries (14.8% vs. 6.5%, p = 0.05). Patients managed during the post-ET period had reduced short (8.5% vs. 17.4%, p = 0.048) and long-term mortality (Log-rank = 0.001). In multivariate analysis of risk factors for long-term mortality, period (pre- or post-ET) was not found to be significantly associated with the mortality. CONCLUSION: Establishment of an ET was associated with faster and more intensive evaluation of patients with IE. During the period of an ET activity, mortality rates were reduced compared with the previous period.

Abdominal Surgery in Patients with a Ventricular Assist Device: A Single Center Experience in Israel.

BACKGROUND: Left ventricular assist devices (LVADs) are used more commonly in patients with advanced-stage heart failure. Some of these patients may require elective or urgent abdominal surgical procedures. OBJECTIVES: To determine the outcomes of the management of LVAD-supported patients who underwent elective and urgent abdominal surgical procedures in our institution. METHODS: A retrospective review was conducted on 93 patients who underwent LVAD implantation between August 2008 and January 2017. All abdominal surgeries in these patients were studied, and their impact on postoperative morbidity and mortality Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patientswas evaluated. RESULTS: Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patients. CONCLUSIONS: It is safe to perform elective abdominal procedures for LVAD-supported patients. The prognosis of these patients undergoing emergency surgery is poor and has high mortality and morbidity rates.

Cardiac Fibroblast-Induced Pluripotent Stem Cell-Derived Exosomes as a Potential Therapeutic Mean for Heart Failure.

The limited regenerative capacity of the injured myocardium leads to remodeling and often heart failure. Novel therapeutic approaches are essential. Induced pluripotent stem cells (iPSC) differentiated into cardiomyocytes are a potential future therapeutics. We hypothesized that organ-specific reprogramed fibroblasts may serve an advantageous source for future cardiomyocytes. Moreover, exosomes secreted from those cells may have a beneficial effect on cardiac differentiation and/or function. We compared RNA from different sources of human iPSC using chip gene expression. Protein expression was evaluated as well as exosome micro-RNA levels and their impact on embryoid bodies (EBs) differentiation. Statistical analysis identified 51 genes that were altered (p ≤ 0.05), and confirmed in the protein level, cardiac fibroblasts-iPSCs (CF-iPSCs) vs. dermal fibroblasts-iPSCs (DF-iPSCs). Several miRs were altered especially miR22, a key regulator of cardiac hypertrophy and remodeling. Lower expression of miR22 in CF-iPSCs vs. DF-iPSCs was observed. EBs treated with these exosomes exhibited more beating EBs p = 0.05. vs. control. We identify CF-iPSC and its exosomes as a potential source for cardiac recovery induction. The decrease in miR22 level points out that our CF-iPSC-exosomes are naïve of congestive heart cell memory, making them a potential biological source for future therapy for the injured heart.

The Clinical SYNTAX score predicts survival better than the SYNTAX score in coronary revascularization.

BACKGROUND: The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial showed that the SYNTAX score (SS) is a useful tool for customizing revascularization treatment for patients with multivessel coronary disease. In the past decade, the Clinical SS (CSS) has emerged as a comprehensive tool. This novel tool considers the SS as well as patient clinical parameters such as age, creatinine clearance, and ejection fraction, which were shown to be relevant for patient prognosis. Thus, in the current work we set out to compare the survival predictive values of the SS versus the CSS and their future application in real-world implementation of the revascularization guidelines. METHODS: This study was a subanalysis of data collected in a prospective national registry in Israel that enrolled consecutive patients with left main and/or 2- to 3-vessel coronary artery disease involving the proximal or mid-left anterior descending artery; the MULTI-vessel Coronary Artery Disease (MULTICAD). The revascularization method was chosen by the physicians taking care of the patients at each hospital and the patients were followed for 5 years. Patients were categorized according to their SS, the CSS, and their revascularization method (primary coronary intervention [PCI] vs coronary artery bypass grafting [CABG]) and patient survival were compared. RESULTS: A total of 585 patients were enrolled in the study and were followed for 5 years. The median CSS was 27, with 288 patients showing a CSS ≥27, with a mean CSS of 47.85 and a mean SS of 29.05. At 3 and 5 years post-treatment, the CSS ≥27 group had a lower survival probability, CSS ≥27 was associated with a lower survival probability among patients who underwent PCI compared with those who underwent CABG. More specifically, the high-CSS CABG group had a 5-year mortality rate of 16.8%, whereas the high-CSS PCI group had a 5-year mortality rate of 32.2%. In a comparison of SS with CSS for the 5-year mortality outcome prediction, CSS was superior to SS with a higher area under the curve. CONCLUSIONS: This prospective registry of real-world revascularization strategies in patients with multivessel disease showed that CSS is a better predictive tool of postrevascularization survival than SS. Moreover, it showed that surgical revascularization in patients with CSS ≥27 is associated with better all-cause mortality outcome after CABG as compared with after PCI. This attests to the need for a score that considers clinical parameters in a real-world scenario.

The Usefulness of the CHA2DS2-VASc Score to Predict Outcomes in Patients with Infective Endocarditis.

Introduction: Despite diagnostic and therapeutic advances, infective endocarditis (IE) is still associated with high mortality rates. Currently, there are no good prognostic tools for the risk assessment of patients with IE. The CHA2DS2-VASc score, used to estimate the risk of ischemic stroke in patients with non-valvular atrial fibrillation (AF), has been shown to be a powerful predictor of stroke and death in patients without known AF associated with other cardiovascular conditions. Objective: We aimed to evaluate the usefulness of the CHA2DS2-VASc score as a prognostic tool in a population of patients with IE. Methods: The Rabin Medical Center Endocarditis Team (RMCET) registry is a retrospective cohort of all patients evaluated at our center due to acute or sub-acute bacterial endocarditis. The CHA2DS2-VASc score was extracted for all patients. All-cause mortality was depicted for all patients. Results: The cohort included 330 patients with a mean age of 65.2 ± 14.7 years (70% men). During a median follow-up of 24 months [IQR 4.7-48.6], 121 (36.7%) patients died. The median CHA2DS2-VASc score was 3, and any score above 2 was associated with increased overall mortality (50.8% vs. 19.9%, p < 0.001). A multivariate model incorporating important confounders not included in the CHA2DS2-VASc model showed consistent results with a risk increase of 121% for the higher CHA2DS2-VASc score groups (HR 2.21 [CI 1.12-4.39], p = 0.023). Conclusions: IE currently has no good risk stratification models for clinical practice. The CHA2DS2-VASc score might serve as a simple and available tool to stratify risk among patients with IE.

Exergaming in patients with a left ventricular assist device: a feasibility study.

AIMS: Exercise games (exergames) have been recently proposed as a mode of facilitating physical activity in patients with chronic diseases. Although patients supported with left ventricular assist devices (LVADs) benefit from physical activity, specific LVAD-related issues hinder their ability to exercise properly. The objective of this study was to assess the feasibility and safety of exergaming in LVAD-supported patients. METHODS AND RESULTS: Eleven LVAD-supported patients were enrolled in a 4 week exergaming programme using Nintendo Wii console with five sport games. Patients were instructed to play for 30 min a day, 5 days a week. Data on exercise capacity and exergaming were collected by using the 6 min walk test (6MWT) and a daily self-report diary, respectively. Feasibility of using the console and its safety was assessed by a semi-structured patient interview. Quality of life was assessed by the Minnesota Living with Heart failure Questionnaire (MLHFQ) and the Cantril's Ladder of Life. Safety was assessed by patient's report in interview and diary. The study group consisted of 10 male patients and 1 female patient, mean age of 67 ± 7 years, of whom 10 were supported with the HeartMate 3 LVAD for a median of 10 (interquartile range 3, 21) months. Baseline exercise capacity assessed by the 6MWT ranged from 240 to 570 m (mean 448 ± 112). After 4 weeks of exergaming, 6MWT distance increased from a mean of 448 ± 112 (evaluated in six patients) to 472 ± 113 m (P = 0.023). Patients' Cantril's Ladder of Life score improved numerically from an average of 6.13 to 7.67, as did their MLHFQ score from 45.9 ± 27 to 38.7 ± 18, with higher and lower scores, respectively, reflecting higher quality of life. No specific LVAD-related safety issues regarding exergaming were reported. CONCLUSIONS: Exergaming was found to be a safe and feasible mode for encouraging physical activity in LVAD-supported patients and carries a potential for improving exercise capacity and quality of life in these patients. Larger scale studies are warranted to further investigate the effect of exergaming in this patient population.

An unusual case report of transcatheter aortic valve implantation-related actinomycosis endocarditis.

Background: Actinomycosis is a chronic invasive infection caused by Actinomyces species. Actinomycosis endocarditis has been described, yet considered rare. We present the first reported transcatheter aortic valve implantation (TAVI)-related actinomycosis endocarditis. Case summary: A 70-year-old female patient, presented 4 months after TAVI with malaise and vocal-cord paralysis. She underwent computed tomography angiography which demonstrated a 28 mm pseudoaneurysm of the ascending aorta, which compressed the laryngeal nerves. Her condition rapidly deteriorated with cardiogenic shock and required an emergent surgery, which reviled a tamponade with active bleeding, due to an ascending aortic dissection. She underwent aortic valve and ascending aorta replacement. A 2 cm vegetation was found on the TAVI prosthetic valve and sent for cultures, which later revealed an Actinomyces neuii infection. Long-term intravenous ampicillin treatment was given. Discussion: This case describes a patient with endocarditis on TAVI prosthetic valve, with an unusual clinical presentation and rapid deterioration to an emergency intervention. This unique presentation of tumour-like tissue invasion is characteristic of actinomycosis, and should be suspected especially following valve replacement.

Monitoring platelet reactivity during prasugrel or ticagrelor washout before urgent coronary artery bypass grafting.

OBJECTIVES: Patients with acute myocardial infarction pretreated with prasugrel or ticagrelor may require urgent coronary artery bypass grafting (CABG). However, prasugrel and ticagrelor withdrawal period is recommended for 5-7 days before planned CABG to enable full platelet recovery. We hypothesized that monitoring sequential platelet reactivity (PR) could identify patients with early platelet recovery who may benefit from earlier surgery before the guideline-recommended 5-7 day delay. PATIENTS AND METHODS: We performed preoperative PR assays in 35 patients with acute myocardial infarction who received prasugrel (60%) or ticagrelor (40%) and required an urgent CABG. When platelet inhibition levels were favorable, on the basis of the VerifyNow assay, surgery was endorsed. CABG-related bleeding parameters were collected and compared with two matched control groups composed of patients who received fewer potent antiplatelet regimens. RESULTS: On the basis of platelet function monitoring, we identified 21 (56.7%) patients with a relatively earlier platelet recovery who underwent CABG before the end of the conventional washout period (5-7 days). For these patients, the washout periods were shortened to an average time of 2.6±1.0 days for ticagrelor and 3.8±1.5 days for prasugrel. CABG-related bleeding parameters were comparable with the two matched control groups. CONCLUSION: A strategy of performing preoperative PR assays can identify patients who recover platelet function in less than 5-7 days after ticagrelor or prasugrel discontinuation. This strategy may provide the basis for performing urgent CABGs earlier than the currently recommended delay. Future, larger studies are required to establish these preliminary findings.

Multiple arterial revascularization using the tangential K-graft technique.

The tangential K graft is a comfortable surgical technique aiming to increase cardiac surgeons' versatility in performing multiple arterial grafting using only two arterial conduits. One end of the free graft--either the right internal thoracic artery (RITA) or the radial artery (RA)--is attached to a marginal circumflex branch. Its other end is anastomosed end to side to a diagonal branch. After the left internal thoracic artery (LITA) is attached to the left anterior descending coronary artery, a wide-open side-to-side LITA to free RITA or RA anastomosis--resembling the letter K--is constructed.