Aims The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE). Methods and results Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). 18F-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated. Conclusion Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.
Purpose High mortality and a limited performance of valvular surgery are typical features of infective endocarditis (IE) in octogenarians, even though surgical treatment is a major determinant of a successful outcome in IE. Methods Data from the prospective multicentre ESC EORP EURO-ENDO registry were used to assess the prognostic role of valvular surgery depending on age. Results As compared to < 80 yo patients, ≥ 80 yo had lower rates of theoretical indication for valvular surgery (49.1% vs. 60.3%, p < 0.001), of surgery performed (37.0% vs. 75.5%, p < 0.001), and a higher in-hospital (25.9% vs. 15.8%, p < 0.001) and 1-year mortality (41.3% vs. 22.2%, p < 0.001). By multivariable analysis, age per se was not predictive of 1-year mortality, but lack of surgical procedures when indicated was strongly predictive ). By propensity analysis, 304 ≥ 80 yo were matched to 608 < 80 yo patients. Propensity analysis confirmed the lower rate of indication for valvular surgery (51.3% vs. 57.2%, p = 0.031) and of surgery performed (35.3% vs. 68.4%, p < 0.0001) in ≥ 80 yo. Overall mortality remained higher in ≥ 80 yo (in-hospital: HR 1.50[1.06-2.13], p = 0.0210; 1-yr: HR 1.58[1.21-2.05], p = 0.0006), but was not different from that of < 80 yo among those who had surgery (in-hospital: 19.7% vs. 20.0%, p = 0.4236; 1-year: 27.3% vs. 25.5%, p = 0.7176). Conclusion Although mortality rates are consistently higher in ≥ 80 yo patients than in < 80 yo patients in the general population, mortality of surgery in ≥ 80 yo is similar to < 80 yo after matching patients. These results confirm the importance of a better recognition of surgical indication and of an increased performance of surgery in ≥ 80 yo patients.
26-years-old man, occasional cannabis smoker, attended the emergency department due to chest pain and epigastralgia for the past 24h, after cannabis consumption. Electrocardiogram revealed ST-segment elevation with Q-waves in V3-V5 and inferior leads. Transthoracic echocardiogram presented: (1) cardiac chamber dilation; (2) severely reduced biventricular systolic function; (3) hypokinesia of left ventricle basal segments of the anterior, lateral and septal walls; (4) scar appearance of the posterior wall and ventricular apex; (5) apical thrombus. Emergent cardiac catheterization showed thrombus located at the medial and distal segments of the left anterior descending artery (LAD), occlusion of the first obtuse marginal (OM) artery and thrombus at the medial and distal segments of the right coronary artery. Angioplasty of the OM was unsuccessful and hypocoagulation was initiated. The patient started veno-arterial ECMO. Immunological study was normal. His clinical condition deteriorated with multiple organ dysfunction, and he died after 20 days. The autopsy revealed coronary atherosclerosis with fibrous plaques causing 80% stenosis of the LAD with two sub-occlusive thrombus, occlusion of the circumflex artery, 70% stenosis of the posterior descending artery, two areas of myocardial infarction and several intracardiac thrombus. We aim to discuss the possible aetiologies for the thrombus formation. The association between cannabis and acute coronary syndromes has been reported and in cases of young adults with chest pain this diagnosis should be considered. Alternatively, our patient presented dilated cardiac chambers with scar walls and presence of intracardiac thrombus that could be the cause of systemic embolization in an undiagnosed dilated cardiomyopathy.
Background Chronotropic incompetence (CI) is defined as the inability to increase heart rate (HR) in response to increased activity. It is common in patients (pts) with cardiovascular (CV) disease, being a predictor of major adverse CV events; however, its importance is often underestimated in clinical practice. Purpose Evaluate the prognostic value of CI in pts with known coronary artery disease (CAD) who performed Bruce protocol treadmill testing. Methods Unicentric, retrospective analysis of consecutive pts with known CAD who underwent Bruce protocol treadmill testing between 2009 and 2010. Chronotropic index (ChI) was calculated as:(peak HR–resting HR)/(220–age–resting HR). CI was defined as ChI < 80% (< 62% in pts prescribed with beta-blockers). Pts were divided in two groups-G1: CI and G2: normal chronotropic response. Events were defined as: de novo heart failure (HF), CAD progression, myocardial infarction (MI), stroke, all-cause mortality and CV mortality. Results A total of 471 pts were included (87.3% male, mean age 69 ± 9.8 years). Mean follow-up was 9.7 years. The groups were similar regarding sex, age, body mass index, diabetes, arterial hypertension, dyslipidemia, MI and left ventricle ejection fraction (P > 0.050). CI was identified in 27.4% pts. Comparing G1 vs. G2, no differences were found related to all-cause mortality, de novo HF, CAD progression, MI and stroke (P > 0.050). However, statistically significant differences were found regarding CV mortality (P = 0.028). Conclusion CI is a simple an easily available parameter that shows a clear association with CV mortality in a long-term follow-up of pts with CAD.
A 44-year-old female with nonrelevant medical history was admitted due to chest pain. She was hemodynamically stable. Normal physical examination. ECG with ST-segment depression in the inferior leads. Echocardiogram had no contractility abnormalities. High-sensitivity troponin I (hsTnI) of 164.4 pg/mL. Non-ST-segment elevation myocardial infarction (NSTEMI) diagnosis was made. 12 hours later she developed refractory chest pain. Emergent coronariography depicted independent ostia for the anterior descending and circumflex arteries and type 1 spontaneous coronary artery dissection (SCAD) of the circumflex artery. During angiography, pain subsided and a conservative approach was adopted. An hour later, she had recurrent pain refractory to medical treatment and new onset of persistent ST-segment elevation in leads V4-V6. It was decided to perform percutaneous coronary intervention and a drug eluting stent was placed in the proximal circumflex artery. There was distal propagation of the parietal hematoma, but TIMI 3 flow was restored. She was discharged on day 6. 5 days later she was readmitted due to NSTEMI. She had recurrent episodes of chest pain followed by reelevation of hsTnI. Coronary computer tomography depicted distal progression of the dissection with involvement of a first obtuse marginal and distal circumflex. After uptitration of anti-ischemic medication she was discharged. The case underlines the challenging and non-linear approach of SCAD in the setting persistent chest pain. Besides the technical difficulties of angioplasty, with higher risk of restenosis and stent failure, most recommendations support a conservative approach. However, persistent chest pain imply further action, as exemplified in this case report.
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