Infective Endocarditis in Belgium: Prospective Data in Adults from the ESC EORP European Endocarditis Registry.

(1) Background: infective endocarditis (IE) is a significant health concern associated with important morbidity and mortality. Only limited, often monocentric, retrospective data on IE in Belgium are available. This prospective study sought to assess the clinical characteristics and outcomes of Belgian IE patients in the ESC EORP European endocarditis (EURO-ENDO) registry; (2) Methods: 132 IE patients were identified based on the ESC 2015 criteria and included in six tertiary hospitals in Belgium; (3) Results: The average Belgian IE patient was male and 62.8 ± 14.9 years old. The native valve was most affected (56.8%), but prosthetic/repaired valves (34.1%) and intracardiac device-related (5.3%) IE are increasing. The most frequently identified microorganisms were S. aureus (37.2%), enterococci (15.5%), and S. viridans (15.5%). The most frequent complications were acute renal failure (36.2%) and embolic events (23.6%). Cardiac surgery was effectively performed when indicated in 71.7% of the cases. In-hospital mortality occurred in 15.7% of patients. Predictors of mortality in the multivariate analysis were S. aureus (HR = 2.99 [1.07-8.33], p = 0.036) and unperformed cardiac surgery when indicated (HR = 19.54 [1.91-200.17], p = 0.012). (4) Conclusion: This prospective EURO-ENDO ancillary analysis provides valuable contemporary insights into the profile, treatment, and clinical outcomes of IE patients in Belgium.

Prevalence and Outcomes of Patients With Discordant High-Gradient Aortic Stenosis.

BACKGROUND: Conflicting prognostic results have been reported in patients with discordant high-gradient aortic stenosis ([DHG-AS] the combination of a mean pressure gradient ≥40 mm Hg and an aortic valve area [AVA] >1 cm2). Moreover, existing studies only included selected patients without concomitant aortic regurgitation. OBJECTIVES: The authors assessed the prevalence and survival of patients presenting with DHG-AS in an unselected group of consecutive patients presenting to the echocardiography laboratory of a tertiary referral center. METHODS: A total of 3,547 adult patients with AVA ≤1.5 cm2 and peak aortic jet velocity ≥2.5 m/s or mean gradient ≥25 mm Hg who presented between 2005 and 2015 were included. Baseline clinical and echocardiographic data, and, when available, aortic valve calcium (AVC) score were collected in an institutional database, with subsequent retrospective analysis. The primary endpoint was all-cause mortality during follow-up. RESULTS: DHG-AS was observed in 163 patients (11.6% of patients with a high gradient). After adjustment for potential confounders, overall mortality rate of patients with DHG-AS was similar to that of patients with concordant severe aortic stenosis (HR: 0.98 [95% CI: 0.66-1.44]; P = 0.91), and patients with discordant low-gradient aortic stenosis (HR: 0.85 [95% CI: 0.58-1.26]; P = 0.42), and higher than concordant moderate aortic stenosis (HR: 0.54 [95% CI: 0.36-0.81]; P = 0.003). After adjustment for aortic velocities, aortic regurgitation had no significant impact on survival. AVC was higher than in patients with concordant moderate aortic stenosis and discordant low-gradient aortic stenosis, and not significantly different from that of concordant severe aortic stenosis. CONCLUSIONS: DHG-AS is not uncommon. Whereas AVA >1.0 cm2 is often seen as moderate aortic stenosis, a high-pressure gradient conveys a poor prognosis, whatever the AVA and the severity of concomitant aortic regurgitation.

Papillary muscle rupture without severe mitral regurgitation following percutaneous balloon mitral commissurotomy: a case report.

Background: Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting. Case summary: A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery. Discussion: We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC.

Diagnostic Role of Incidental Premature Contractions During Doppler Echocardiography.

Cardiac sonographers often perceive premature beats as a limiting factor during echocardiography because they alter filling and contractility, and loops recorded during or after a premature contraction are often discarded. Here we present 2 cases in which the incidental occurrence of premature beats on Doppler echocardiography contributed to the diagnosis. (Level of Difficulty: Intermediate.).

Sarcoidosis presenting as acute pericarditis. A case report and review of pericardial sarcoidosis.

Cardiac sarcoidosis typically involves the myocardium. Pericardial effusion is uncommon, and symptomatic pericardial disease is even more infrequent. We report the case of a patient presenting with pericarditis as the first manifestation of sarcoidosis. A 50-year-old previously healthy man presented with chest pain and dyspnoea. The electrocardiogram confirmed the diagnosis of pericarditis. Computed tomography of the thorax showed pulmonary infiltrates with mediastinal and hilar adenopathies. Histological analysis of a lymph node biopsy was consistent with sarcoidosis. There was no evidence of myocardial involvement on Magnetic Resonance Imaging (MRI). We reviewed the available English literature and identified 31 cases with sarcoidosis and pericardial involvement. The majority of cases presented as pericardial effusion, which was often the first clinical manifestation of the disease. Pathological diagnosis usually occurs at extra-cardiac locations. Myocardial involvement, an important cause of morbidity and mortality, was found in 25.8% (8/31) of cases. Sarcoidosis should be considered in the differential diagnosis of patients presenting with pericardial disease. The optimal treatment regimen and long-term outcome remain largely unknown. Research in cardiac sarcoidosis should include pericardial disease as a separate manifestation in order to improve the management of this rare but likely underdiagnosed condition.

Right ventricular longitudinal fractional shortening: a substitute to right ventricular free wall longitudinal strain?

PURPOSE: Because of its diagnostic and prognostic value, right ventricular strain assessed by speckle-tracking imaging (RVS) has been incorporated into echocardiographic guidelines. However, it suffers from limitations including the need of good image quality and of dedicated software with inter-vendor variability. We hypothesized that RV free wall longitudinal fractional shortening (LFS) could be used as a substitute to RVS, without suffering from the aforementioned limitations. METHODS: We aimed to establish in a series of non-selected consecutive patients in sinus rhythm the value of LFS, calculated as [-(TAPSE/RVdiastolic length)] and of several common echocardiographic and Doppler parameters to predict an abnormal RV function, defined as RVS > - 20.2%. RESULTS: Among 144 consecutive patients, poor image quality precluded the assessment of RVS and of LFS in 31 and 4 patients, respectively (P = 0.0018), resulting in a final study group of 113 patients. The intraclass correlation coefficients for inter- and intra-observer variability were 0.97 (95% CI 0.92; 0.98) and 0.93 (CI 0.92; 0.98) for LFS and RVS, respectively. Among all tested RV function indices, LFS best correlated with RVS (R 0.97, 95% CI 0.81; 0.91). Bland-Altman analysis for the comparison between LFS and RVS showed no systematic bias. The area under the ROC-curve of the various RV function indices to detect abnormal RVS was best for LFS (0.97, 95% CI 0.94-1), with sensitivity, specificity, negative and positive predictive value of 83%, 96%, 96%, and 83%, respectively. CONCLUSION: LFS performs reasonably well to predict abnormal RVS and is more often feasible than RVS.

The RV1-V3 transition ratio: A novel electrocardiographic criterion for the differentiation of right versus left outflow tract premature ventricular complexes.

BACKGROUND: Several electrocardiographic (ECG) indices have been proposed to predict the origin of premature ventricular complexes (PVCs) with precordial transition in lead V3. However, the accuracy of these algorithms is limited. OBJECTIVES: We sought to evaluate a new ECG criterion differentiating the origin of outflow tract with precordial transition in lead V3. METHODS: We included in our study patients exhibiting outflow tract PVCs with precordial transition in lead V3 referred for ablation. We analyzed a novel new ECG criterion, RV1-V3 transition ratio, for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V3. The RV1-V3 transition ratio was defined as (RV1+RV2+RV3) PVC / (RV1+RV2+RV3) SR (sinus rhythm). RESULTS: We included 58 patients in our study. The ratio was lower for right ventricular outflow tract origins than left ventricular outflow tract (LVOT) origins (median [interquartile range], 0.6953 [0.4818-1.0724] vs 1.5219 [1.1582-2.4313], P < .001). Receiver operating characteristic analysis revealed an area under the curve of 0.856 for the ratio, and a cut-off value of ≥0.9 predicting LVOT origin with 94% sensitivity and 73% specificity. This ratio was superior to any previously proposed ECG criterion for differentiating right from left outflow tract PVCs. CONCLUSION: The RV1-V3 transition ratio is a simple and accurate novel ECG criterion for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V3.

Role of imaging for diagnosis and management of aortic valve papillary fibroelastoma and cardiac amyloid light chain amyloidosis: a case report.

BACKGROUND: We report the case of a patient who presented with concomitant aortic valve papillary fibroelastoma (PFE) and cardiac amyloidosis. Although histologically benign, PFE confers an increased thromboembolic risk, and surgical excision is often indicated. However, outcomes of cardiac surgery are poor in patients with cardiac amyloidosis. CASE SUMMARY: A 61-year-old man with complaints of dyspnoea and weight loss of 10 kg developing over the past 5 months was evaluated in the cardiology clinic. Echocardiography revealed sessile aortic valve PFE and was also highly suggestive of cardiac amyloidosis. The diagnosis of amyloid light chain amyloidosis secondary to indolent multiple myeloma was eventually confirmed. Therapy with daratumumab, bortezomib, cyclophosphamide, and dexamethasone allowed full remission over a 6-month period and resulted in marked improvement in symptoms and cardiac function as evaluated by global longitudinal strain. Further workup with cerebral magnetic resonance revealed multiple vascular sequelae. Surgical removal of the aortic fibroelastoma with bioprosthetic aortic valve replacement was performed successfully and the patient had an uneventful recovery. DISCUSSION: Papillary fibroelastoma and cardiac amyloidosis are rare and most likely unrelated entities. Concomitant presentation of both conditions in the same patient presents a unique therapeutic challenge. By allowing cardiac function to be monitored during chemotherapy, speckle-tracking echocardiography can prove instrumental in determining the optimal timing of surgical intervention.

Predictors of recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation.

AIMS: Catheter ablation of paroxysmal atrial fibrillation (AF) reduces AF recurrence, AF burden, and improves quality of life. Data on clinical and procedural predictors of arrhythmia recurrence are scarce and are flawed by the high rate of pulmonary vein reconnection evidenced during repeat procedures after pulmonary vein isolation (PVI). In this study, we identified clinical and procedural predictors for AF recurrence 1 year after CLOSE-guided PVI, as this strategy has been associated with an increased PVI durability. METHODS AND RESULTS: Patients with paroxysmal AF, who received CLOSE-guided PVI and who participated in a prospective trial in our centre, were included in this study. Uni- and multivariate models were plotted to find clinical and procedural predictors for AF recurrence within 1 year. Three hundred twenty-five patients with a mean age of 63 years (CHA2DS2VASc 1 [1-3], left atrium diameter 41 ± 6 mm) were included. About 60.9% were male individuals. After 1 year, AF recurrence occurred in 10.5% of patients. In a binary logistic regression analysis, the diagnosis-to-ablation time (DAT) was found to be the strongest predictor of AF recurrence (P = 0.011). Diagnosis-to-ablation time ≥1 year was associated with a nearly two-fold increased risk for developing AF recurrence. CONCLUSION: The DAT is the most important predictor of arrhythmia recurrence in low-risk patients treated with durable pulmonary vein isolation for paroxysmal AF. Whether reducing the DAT could improve long-term outcomes should be investigated in another trial.

Prospective Randomized Evaluation of High Power During CLOSE-Guided Pulmonary Vein Isolation: The POWER-AF Study.

BACKGROUND: CLOSE-guided atrial fibrillation (AF) ablation is based on contiguous (intertag distance ≤6 mm), optimized (Ablation Index >550 anteriorly and >400 posteriorly) point-by-point radiofrequency lesions. The optimal radiofrequency power remains unknown. METHODS: The POWER-AF study is a prospective, randomized controlled monocentric study including patients with paroxysmal AF, planned for first CLOSE-guided pulmonary vein isolation using a contact force radiofrequency catheter (Thermocool SmartTouch, Biosense Webster, Inc, Irvine, CA). A total of 100 patients were randomized into 2 groups (1:1). The control group received AF ablation using the standard CLOSE protocol (35 W), whereas in the experimental group, pulmonary vein isolation was performed using high power (45 W). Endoscopic evaluation was performed in patients with intraesophageal temperature rise >38.5 °C. RESULTS: The resulting sample size was 96 (48+48) patients. In the high power group, shorter procedure time (80 versus 102 minutes, P<0.001), shorter total radiofrequency application time (16 versus 26 minutes, P<0.001), and radiofrequency time per application (26 versus 37 s anteriorly, P<0.001 and 13 versus 17 s posteriorly, P<0.001) were observed. Endoscopic evaluation (performed in 19/48 versus 25/48 patients respectively, P=0.31) showed an ulcerative perforation in a high power group patient (treated by endoscopic stenting and normalization after ≈4 months) and a superficial ulcerative lesion in a control group patient (conservative treatment). Both occurred following excessive Ablation Index applications (up to 460 and 480, respectively) with excessive contact force (30 g on average, with peaks up to 50 g). Six-months AF recurrence was not significantly different (10% in high power versus 8% in control, P=0.74). CONCLUSIONS: This randomized controlled study shows that a 45 W radiofrequency power CLOSE protocol in patients with paroxysmal AF significantly increases the global procedural efficiency with similar midterm efficacy. However, our study showed a narrower safety margin and a limited increased efficiency at the posterior wall using high power. This advocates against the use of high power in the region neighboring the esophagus.