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Objective-To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients. Design-Cohort analysis based on a prospective inclusive registry. Setting-205 consecutive patients (> 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands. Results-The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually oVered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment. Conclusions-In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.

Echocardiography may miss prosthetic heart valve (PHV) endocarditis which advocates for novel imaging techniques to improve diagnostic accuracy and patient outcome. The purpose of this study was to determine the complementary diagnostic value of cardiac computed tomography angiography (CTA) to the clinical routine workup including transthoracic and transesophageal echocardiography (TTE/TEE) in patients with suspected PHV endocarditis and its impact on patient treatment. A diagnostic prospective cross-sectional study was chosen as design. Besides clinical routine workup (including TTE/TEE), CTA was performed to assess its diagnostic accuracy and complementary diagnostic/therapeutic value. For the diagnostic accuracy, the reference standard was surgical findings or clinical follow-up. To determine the complementary diagnostic/therapeutic value an expert-panel was used as reference standard. Twenty-eight patients were included. CTA resulted in a major diagnostic change in six patients (21 %) mainly driven by novel detection of mycotic aneurysms by CTA. Furthermore, treatment changes occurred in seven patients (25 %) compared to clinical routine workup. Diagnostic accuracy of routine clinical workup plus CTA was superior to clinical routine workup alone for the detection of PHV endocarditis in general, vegetations and peri-annular extension. This study demonstrates that CTA and clinical workup including TTE and TEE are complementary in patients with PHV endocarditis. Therefore, CTA imaging has to be considered after clinical routine workup in patients with a high suspicion on PHV endocarditis.

ObjectivesMultimodal non-invasive imaging plays a key role in establishing a diagnosis of PHV endocarditis. The objective of this study was to provide a systematic review of the literature and meta-analysis of the diagnostic accuracy of TTE, TEE, and MDCT in patients with (suspected) PHV endocarditis.MethodsStudies published between 1985 and 2013 were identified via search and cross-reference of PubMed/Embase databases. Studies were included if (1) they reported on the non-invasive index tests TTE, TEE, or MDCT; (2) data was provided on PHV endocarditis as the condition of interest; and (3) imaging results were verified against either surgical inspection/autopsy or clinical follow-up reference standards, thereby enabling the extraction of 2-by-2 tables.ResultsTwenty articles (including 496 patients) met the inclusion criteria for PHV endocarditis. TTE, TEE, and MDCT + TEE had a pooled sensitivity/specificity for vegetations of 29/100 %; 82/95 %, and 88/94 %, respectively. The pooled sensitivity/specificity of TTE, TEE, and MDCT + TEE for periannular complications was 36/93 %, 86/98 %, and 100/94 %, respectively.ConclusionsTEE showed good sensitivity and specificity for establishing a diagnosis of PHV endocarditis. Although MDCT data are limited, this review showed that MDCT in addition to TEE may improve sensitivity in detecting life-threatening periannular complications.Key Points• Multimodal imaging is an important ingredient of diagnostic workup for PHV endocarditis.• Transthoracic and transesophageal echography may miss life-threatening periannular complications.• MDCT can improve sensitivity for the detection of life-threatening periannular complications.Electronic supplementary materialThe online version of this article (doi:10.1007/s00330-015-3605-7) contains supplementary material, which is available to authorized users.

NR is related with in-hospital mortality and residual pulmonary hypertension after PEA. NR > 1.0 is associated with a higher risk of such unfavourable outcomes. NR may be considered a determinant of eligibility for PEA.

Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context.

High CRP level after 1 week of treatment and a slow percentage decline in CRP level during the first week of treatment are indicators of poor clinical outcome.

AimsDespite improvement in prognosis for ST-elevation myocardial infarction (STEMI) patients, mortality remains high in STEMI patients presenting with cardiogenic shock (CS). Right ventricular (RV) dysfunction is an established independent predictor for adverse prognosis in STEMI patients without CS. The purpose of our study was to determine the prognostic value of RV dysfunction on admission in STEMI patients presenting in CS. Methods and resultsTwo hundred and ninety-two consecutive STEMI patients with CS on admission were treated by primary percutaneous coronary intervention (PCI) from January 1997 through March 2005. RV function was assessed by measurement of tricuspid annular plane systolic excursion (TAPSE) on early echocardiography in 184 of 292 patients. Right ventricular dysfunction was defined as a TAPSE of 14 mm. Right ventricular dysfunction was present on early echocardiography in 70 of 184 patients (38%). The Kaplan-Meier estimate for overall 4-year survival was 57%. KaplanMeier estimates for 4-year survival in patients with and without RV dysfunction were 33 and 73%, respectively (P , 0.001). Cox-regression analysis revealed a hazard ratio of 2.1 (95% CI 1.3 -3.4, P ¼ 0.002) for RV dysfunction when adjusted for age, glucose on admission, and LVEF , 40%. In patients with and without RV dysfunction, the right coronary artery was the infarct-related artery in 41 and 28% of patients, respectively (P ¼ 0.06). ConclusionIn STEMI patients presenting with CS on admission and treated with primary PCI, RV dysfunction as assessed by echocardiography is an independent predictor for long-term mortality.--