Appropriate use criteria for echocardiography in the Netherlands.

INTRODUCTION: Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way. METHODS: All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively). RESULTS: Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper. CONCLUSIONS: Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity.

Prognostic factors in infective endocarditis in general hospitals in the Netherlands.

INTRODUCTION: Despite advances in treatment, infective endocarditis (IE) still ranks amongst the most lethal infectious diseases. We sought to determine prognostic factors in general hospitals in the Netherlands as research in this setting is scarce. RESULTS: Between 2004 and 2011, we identified 216 cases of IE, 30.1 % of which were prosthetic valve IE. This leads to an annual incidence of IE of 5.7 new cases per 100,000 persons per year. Women were less likely to undergo surgical intervention (OR = 1.96, 95 % CI 1.06-3.61, p = 0.031). Also, ageing was an independent prognostic factor for not receiving surgery in a multivariate analysis (annual OR = 1.04, 95 % CI 1.02-1.06, p < 0.001). Female sex was a prognostic factor for mortality (OR = 2.35, 95 % CI 1.29-4.28, p = 0.005). Age was also an independent prognostic factor for mortality (OR = 1.05, 95% CI 1.03-1.08, p < 0.001). Conservative treatment was a prognostic factor for mortality (OR = 3.39, 95 % CI 1.80-6.38, p < 0.001) whereas surgical intervention was an independent prognostic factor for adverse events (OR = 3.03, 95% CI 1.64-5.55, p < 0.001). Staphylococcus aureus was an independent prognostic factor for adverse events (OR = 2.05, 95 % CI 1.10-3.84, p = 0.024) but not for mortality. CONCLUSION: This study shows that endocarditis in general hospitals has a high rate of morbidity and mortality. Even when treated, it ranks as one of the most lethal infectious diseases in the Netherlands, especially in women and the elderly.

Percutaneous mitral valve repair using the edge-to-edge technique in a high-risk population.

Background. Percutaneous mitral valve (MV) repair using the edge-to-edge clip technique might be an alternative for patients with significant mitral regurgitation (MR) and an unacceptably high risk for operative repair or replacement. We report the short-term safety and efficacy of this new technique in a high-risk population.Methods. All consecutive high-risk patients who underwent percutaneous MV repair with the Mitraclip(®) between January and August 2009 were included. All complications related to the procedure were reported. Transthoracic echocardiography for MR grading and right ventricular systolic pressure (RVSP) measurement were performed before, and at three and 30 days after the procedure. Differences in NYHA functional class and quality of life (QoL) index were reported. Results. Nine patients were enrolled (78% male, age 75.9±9.0 years, logistic EuroSCORE 33.8±9.0%). One patient developed inguinal bleeding. In one patient partial clip detachment occurred, a second clip was placed successfully. The MR grade before repair was ≥3 in 100%, one month after repair a reduction in MR grade to ≤2 was present in 78% (p=0.001). RVSP decreased from 43.9±12.1 to 31.6±11.7 mmHg (p=0.009), NYHA functional class improved from median 3 (range 3 to 4) to 2 (range 1 to 4) (p=0.04), and QoL index improved from 62.9±16.3 to 49.9±30.7 (p=0.12). Conclusion. In high-risk patients, transcatheter MV repair seems to be safe and a reduction in MR can be achieved in most patients, resulting in a short-term improvement of functional capacity and QoL. (Neth Heart J 2010;18:437-43.).

Three-dimensional transoesophageal echocardiography in a patient undergoing percutaneous mitral valve repair using the edge-to-edge clip technique.

We report a case of percutaneous mitral valve repair, using the Mitraclip device, in which we show that application of real-time three-dimensional transoesophageal echocardiography (3D-TEE) is extremely helpful for the guidance of this procedure. Because of its excellent visualization capacities, 3D-TEE simplifies the transseptal puncture, the positioning of the clip above the mitral valve orifice, the grasping of the mitral valve leaflets, and the evaluation of the final result. Therefore, we conclude that 3D-TEE has the potential to increase the safety and efficacy of this new technique to treat mitral regurgitation in patients who cannot undergo conventional valve surgery.

New bioabsorbable septal repair implant for percutaneous closure of a patent foramen ovale: short-term results of a single-centre experience.

BACKGROUND: Permanent implants for closure of a patent foramen ovale (PFO) have a number of possible disadvantages including erosions, thrombus formation, and allergic reactions. The incidence of adverse events may be lower using a bioabsorbable device. OBJECTIVE: To evaluate the short-term safety and efficacy of a new bioabsorbable closure device. METHODS: All 35 consecutive patients (21 female, mean age 47.9 +/- 10.8 years), who underwent a percutaneous PFO closure between November 2007 and July 2008, were included. All complications were reported. The efficacy was based on the residual shunting the day after implant and at 1 month follow-up and was graded as minimal, moderate, or severe, using contrast transthoracic echocardiography with the Valsalva manoeuvre. RESULTS: The only in-hospital complication was a surgical device retrieval from the femoral vein. Four patients developed a minimal inguinal haematoma. One day after closure, residual shunting was present in 56% of the patients (minimal 27%, moderate 23% and severe 6%). At 1 month follow-up (n = 33), one patient developed a transient neurological deficit and three patients suffered from paroxysmal atrial fibrillation. A residual shunt at 1 month was present in 45% of the patients (minimal 30%, moderate 12%, and severe 3%). CONCLUSIONS: Percutaneous PFO closure using the bioabsorbable closure device seems to be safe. However, a high rate of residual shunting is present at 1 month follow-up. Long-term follow-up data are necessary to evaluate the efficacy and safety of this device.

[Unexplained right-sided heart failure following open heart surgery: mind the pericardium]. / Onverklaarde rechtsdecompensatie na een openhartoperatie: denk aan het hartzakje.

Three men, aged 67 years, 80 years and 53 years, respectively, developed signs and symptoms of progressive right-sided heart failure following open heart surgery. They were diagnosed with constrictive pericarditis based on echocardiography, cardiac magnetic resonance and cardiac catheterisation. Following pericardiectomy, two of the patients fully recovered, while one, the 80-year-old man, died during convalescence. When signs and symptoms of progressive right-sided heart failure develop after open heart surgery, a diagnosis of constrictive pericarditis should be considered. Constrictive pericarditis after open heart surgery may be caused by inflammation of the pericardium; an old, fibrotic haemopericardium, which may be diffuse or loculated; pericardial adhesions; or a combination of these entities. Diagnosing constrictive pericarditis is difficult and may take a long time. However, it is important to recognise this disorder early before it has progressed to an advanced stage. Pericardiectomy is the only effective therapy. When performed too late, survival is significantly reduced.

Aorta-atrial fistula, a rare complication of prosthetic valve endocarditis.

A 51-year-old male with a history of a mechanical Carbomedics aortic and mitral valve replacement in 2003 and several re-operations because of endocarditis of the mitral valve in 2007 presented with heart failure 68 days after operation. Echocardiography confirmed the presence of a fistulous connection between the aorta and the left atrium. Because of the multiple surgical interventions and high operative risk, an initial conservative medical treatment was initiated and the clinical course was uneventful to this date.

Isolated left ventricular noncompaction in a patient presenting with a subacute myocardial infarction.

Isolated left ventricular noncompaction is a rare cardiomyopathy that is often not recognised. So far, it is not well established how best to manage this abnormality. We describe a patient in whom the diagnosis of isolated left ventricular noncompaction was made after presentation with a subacute myocardial infarction. Because of nonsustained ventricular tachycardias during hospitalisation, which were inducible and deteriorated into ventricular fibrillation on electrophysiological examination after coronary artery bypass grafting, he received an implantable defibrillator. Whether the ventricular tachycardias were due to the myocardial infarction or to the noncompacted myocardium remains uncertain. (Neth Heart J 2007;15:109-11.).

WITHDRAWN: Giant Multiperforated Atrial Septal Aneurysm in a Patient with Paroxysmal Atrial Fibrillation.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 154-156, . The duplicate article has therefore been withdrawn.

[Thrombosis of a coronary stent after discontinuing treatment with clopidogrel]. / Trombose van een coronaire stent na het staken van behandeling met clopidogrel.

A drug-eluting stent was implanted in four patients, a man aged 67 and a woman aged 42 with acute myocardial infarction, a woman aged 41 with unstable angina pectoris and a man aged 41 with stable angina pectoris. All suffered stent thrombosis after discontinuation (in three cases prematurely) of clopidogrel therapy. Reasons for discontinuation included allergic reaction, a dental procedure and refusal of reimbursement by the insurer. In order to restore stent patency they were treated by percutaneous coronary intervention and all patients suffered irreversible myocardial damage. Combination therapy using acetylsalicylic acid and clopidogrel during and after angioplasty for the prevention of long- and short-term complications is necessary. Stent thrombosis after drug-eluting stent implantation usually occurs within 1-4 weeks following discontinuation ofantiplatelet medication. These cases stress the importance of antiplatelet therapy after stent implantation. Physicians, dentists and patients must be aware of the risk of the early discontinuation ofantiplatelet therapy.

Antiplatelet therapy in patients undergoing coronary stenting: The risk of late stent thrombosis.

BACKGROUND: Anticoagulation after coronary stenting is essential to prevent stent thrombosis. Drug-eluting stents, which are the preferred therapy, may be associated with a higher tendency for stent thrombosis. METHODS: Patients who underwent coronary stent placement and presented with late stent thrombosis are described. RESULTS: Eight patients with stent thrombosis are presented. Early discontinuation of the antithrombotic medication is associated with the occurrence of these complications. CONCLUSION: Long-term antithrombotic therapy seems essential to prevent stent thrombosis, especially for patients treated with drug-eluting stents.

Indication and timing of percutaneous mitral balloon valvotomy and the role of atrial fibrillation.

Percutaneous transvenous mitral balloon valvotomy (PTMV) has been proven to be an effective and safe method for treatment of patients with severe mitral valve stenosis. This technique has become an accepted alternative for surgical commissurotomy, not only in young patients with pliable valves, but also in selected older patients with extensive valvular pathology. This review highlights the significance of coexisting atrial fibrillation, patient selection and timing of PTMV in patients with mitral valve stenosis.

An unusual case of cardiomyopathy in a 75-year-old woman.

In this report we describe a 75-year-old woman who presented with an acute coronary syndrome and transient catecholamine-induced cardiomyopathy with severe pulmonary oedema necessitating mechanical ventilation. During mechanical ventilation several episodes of hypertension occurred despite severe left ventricular systolic dysfunction. A pheochromocytoma was diagnosed and after successful surgical resection the patient's condition improved. Three months after surgery myocardial scintigraphic examination demonstrated a normal ejection fraction and no signs of adenosine-induced ischaemia.

Mitral valve repair is not always needed in patients with functional mitral regurgitation undergoing coronary artery bypass grafting and/or aortic valve replacement.

BACKGROUND AND AIM: Functional mitral regurgitation (FMR) is defined as mitral regurgitation in the absence of intrinsic valvular abnormalities. We prospectively evaluated the effect of coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR), without additional mitral valve repair, on the degree of moderate or severe FMR. STUDY DESIGN AND METHODS: From a cohort of 2829 patients undergoing CABG and/or AVR in the St. Antonius Hospital, 67 patients were identified with moderate or severe FMR by transthoracic and transoesophageal Doppler echocardiography. RESULTS: Two out of the 67 patients (3%) died perioperatively. During follow-up (3-18 months) mitral regurgitation decreased by one grade in 29 patients, by two grades in 28, by three grades in five patients and remained unchanged in one patient (p=0.0001). Of all patients, 85% had grade I mitral regurgitation or less. Grade II mitral regurgitation remained in nine patients with a previous large myocardial infarction and/or annular calcifications. NYHA class improved from 3.1+0.5 to 1.4+0.4 (p=0.0001). Ejection fraction increased from 46 to 55% (p=0.0001). Overall, left atrial and left ventricular end-diastolic dimensions decreased significantly. In contrast, no decrease in dimensions was seen in patients with postoperative grade II mitral regurgitation. CONCLUSION: FMR may improve significantly following CABG and/or AVR, although a previous large myocardial infarction and/or annular calcifications may affect outcome.

[Dyspnoea in pregnant female immigrants due to unexpected mitral valve stenosis]. / Dyspnoe bij allochtone zwangeren door onverwachte mitralisklepstenose.

Three female patients, a 22-year-old Moroccan woman, a 25-year-old Turkish woman and a 35-year-old Iraqi woman, became increasingly dyspnoeic during their pregnancy; this was a symptom of congestive heart failure due to mitral valve stenosis. Since all patients were refractory to medical treatment, they underwent invasive therapy by percutaneous transvenous mitral balloon valvotomy (PTMV). In two patients this therapy was successful, but in one patient a closed mitral valvotomy was needed. All three women delivered healthy infants, two immediately following the PTMV; at follow-up 2-4 years later, the women and infants were all doing well. The prevalence of mitral valve stenosis in the western world is increasing because of changing immigration patterns. When pregnant patients start complaining about dyspnoea, especially if they are immigrants, one should be aware of the possibility of mitral valve stenosis. PTMV is a safe and successful treatment for these patients and is preferred above surgical therapy because of its low morbidity and mortality for both mother and foetus. PTMV must be performed in a thoracic surgery centre by an experienced team and the X-ray exposure should be minimised.

Four cardiac myxomas diagnosed three times in one patient.

A left atrial myxoma was surgically removed in a 58-year-old man following several embolic events. Five months later, a new myxoma was found in the right ventricular outflow tract and surgically removed. In this patient, we visualized two more recurrences 14 years later, one in the left atrium and the other in the left ventricle. A short review of the literature concerning recurrent cardiac myxomas is given.