New cardiovascular imaging technologies have strongly influenced the diagnosis of bacterial endocarditis [infective endocarditis (IE)]. The clinical presentation of IE is polymorphic, which explains the difficulty of diagnosis and the delay in treatment. Symptoms such as fever, chills, loss of appetite and weight, and embolic phenomena strongly support the diagnosis of endocarditis, but are not always present, particularly in elderly or immuno-compromised patients. Moreover, subtle symptoms in patients at high risk for the development of IE, such as those with prosthetic valves or intracardiac devices, patients with congenital heart disease, and drug addicts should lead to the suspicion that a diagnosis of IE is highly probable. In this review, we will focus on the diagnosis of complex IE in native valves and prosthetic valves.
Introduction Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is an appealing treatment option for patients with degenerated aortic bioprosthetic valves. However, high post-procedural transprosthetic gradients are very common after ViV-TAVI than after TAVI for native-valve aortic stenosis. Aim We sought to evaluate transprosthetic gradients (ΔP) and hemodynamic outcome in patients undergoing ViV-TAVI according to valve type and balloon post-dilation (balloon-expandable vs self-expandable with and without post-dilation). Material and methods We retrospectively analyzed 111 patients undergoing ViV-TAVI. A balloon-expandable valve was used in 35 patients (32%, Group 1), a self-expandable valve in 76 cases of which 39 (35%, Group 2) without balloon post-dilation and 37 (33%, Group 3) with balloon post-dilation. A comprehensive transthoracic echocardiography (TTE) was performed in all patients at baseline, at discharge and at 6-months follow-up. Results Successful ViV-TAVI was performed in 110 patients (99%). Baseline peak and mean ΔP, left ventricular volumes, ejection fraction, and pulmonary artery systolic pressure were similar among groups. A significant improvement in all echocardiographic parameters was observed in all groups over time (Table 1). In particular, a significant reduction in postprocedural gradients was observed at discharge and at 6-months follow-up compared to baseline in all groups. Immediately after ViV-TAVI procedure, the lowest value of mean ΔP was observed in Group 3 (12±7 mmHg) compared to both Group 1 (20±9 mmHg) and Group 2 (17±8 mmHg, p=0.001). This result was confirmed at 6-months follow-up (p=0.012). Rate of small valve size (≤23 mm) implanted was similar among groups (Group 1: 78%, Group 2: 60%, Group 3: 62%, p=0.123). Similar 1-year all-cause mortality was observed among groups (9%, 13%, 0%, respectively, p=0.135). Conclusions In patients with failed surgical aortic prosthesis, ViV-TAVI is an effective option and is associated with sustained improved hemodynamics in all patients. Anyway, the choice of prosthetic valve type and implantation technique are relevant on residual transprosthetic gradients and should be taken into account for a better long-term outcome. Funding Acknowledgement Type of funding sources: None.
Background The association of speckle tracking echocardiography measures of left ventricular (LV) and right ventricular (RV) strain with clinical outcome in heart failure with reduced and preserved ejection fraction (HFrEF and HFpEF) has been extensively investigated. In fact, while the contribute of LV ejection fraction (LVEF) for prognosis is controversial, myocardial strain has proven to be a strong and independent prognostic predictor in many HF studies. Purpose The aim of this meta-analysis was to assess the prognostic value of LV global longitudinal strain (GLS) and free wall RV longitudinal strain (fwRVLS) by 2-dimensional speckle tracking echocardiography in patients with HFrEF, HF with mildly-reduced ejection fraction (HFmrEF) and HFpEF. Methods A systematic literature search of medical databases including Pubmed, Scopus, Ovid Online, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Scopus was performed using PRISMA principles. All relevant studies in English language reporting the predictive value of LV GLS and/or fwRVLS for mortality and/or cardiovascular events in HFrEF, HFmrEF and HFpEF, with follow up >6 months, were identified. Case reports/series and abstract congresses were excluded (Fig. 1). All-cause mortality and a composite endpoint of cardiovascular death, re-hospitalization for HF, cardiac transplantation, ventricular assist device implantation were analyzed. Hazard ratios (HR) were extracted from univariate and multivariate random-effects models reporting on the association of LV GLS and fwRVLS and outcome and described as pooled estimates with 95% confidence intervals (CI). Results Fifty studies (n=18276 patients) satisfied the inclusion criteria (35 studies in chronic HF, 15 studies in acute HF). Most studies (n=36) included patients with HFrEF, while 14 studies included patients with HFmrEF (n=3) and with HFpEF (n=11); thus HFmrEF and HFpEF were grouped together for the analysis. Overall, 48 studies included LV GLS (median value = −9% [from −17% to −11%], 17 studies included fwRVLS (median value = −18% [from −24% to −14%]). Over a median follow up of 32 [from 7 to 67] months follow up, 5618 (31%) had a cardiovascular event or died. LV GLS and fwRVLS were independently associated with all-cause mortality and the composite outcome, regardless of LVEF (Fig. 2), both in HFrEF (HR 1.26; 95% CI [1.15; 1.37]; p<0.01 for LV GLS and HR 1.06; 95% CI [1.03; 1.09]; p<0.01 for fwRVLS) and in HFpEF (HR 1.07; 95% CI [1.03; 1.12]; p<0.01 for LV GLS and HR 1.08; 95% CI [0.96; 1.21]; p<0.01 for fwRVLS). Conclusions These meta-analysis data demonstrate that LV and RV strain are associated with mortality and cardiovascular events in patients with HF, HFmrEF and HFpEF and may provide important additive prognostic information. These findings emphasize the potential usefulness of LV GLS and fwRVLS in clinical practice to improve the risk stratification and management of patients with HF regardless of LVEF. Funding Acknowledgement Type of funding sources: None.
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