Endocarditis at a large community hospital with on-site cardiac surgery.

OBJECTIVE: Infective endocarditis (IE) is still a serious disease. The currently published EURO-ENDO registry showed a rate of surgery of 51.2% and a lower mortality in operated IE patients. We hypothesized differences between our data and the registry. METHODS: Retrospective single centre registry on the hospital course of patients with IE. RESULTS: In four years, 171 IE patients were treated at our hospital. Mean age of patients was 66.5 ± 13.8 years and 62.6% of patients were transferred from other hospitals. There were 85 (49.7%) patients with native valve IE (NVE), 53 (31%) with prosthetic valve IE (PVE) and 33 (19.3%) with either intra-cardiac device related IE (n = 29) or IE associated with central access lines (n = 4) (DRE). A total of 81.3% (n = 139) of patients were sent to cardiac surgery. Using a logistic regression model to analyse predictors of conservative instead of surgical therapy the only independent variables were: presence of large vegetation or abscesses (OR: 0.36, 95%CI 0.15-0.83; p = 0.016) and age (for each ten years) (OR: 1.61, 95%CI 1.11-2.32, p = 0.01). Hospital mortality was 21.6% (n = 37/171), with no difference (p = 0.97) between those who were operated (21.6%, n = 30/139) and those treated conservatively (21.9%, n = 7/32). Comparing those treated conservatively without an indication for surgery with those with an indication, mortality was 9.5% versus 45.5%, p = 0.02. CONCLUSIONS: In this registry from a hospital with on-site cardiac surgery more than half of patients were referred. The rate of patients treated surgically was 81.3%. Hospital mortality was 21.6%, with no difference between operated and conservatively treated patients.

Transcatheter Mitral Valve Implantation (TMVI) Using Edwards SAPIEN 3 Prostheses in Patients at Very High or Prohibitive Surgical Risk: A Single-Center Experience.

BACKGROUND: Mitral valve surgery in patients with failing bioprosthesis, annuloplasty rings, or in patients with advanced mitral annular calcification (MAC) is associated with high morbidity and mortality rates. Percutaneous antegrade transseptal transcatheter mitral valve implantation (TMVI) has recently successfully been performed in those patients at high or prohibitive surgical risk, but data on patients treated by TMVI are sparse. This study sought to evaluate short- and midterm outcomes of patients treated by TMVI at our site in clinical practice. METHODS AND RESULTS: From October 2016 to February 2018, seven patients (six women and one man) at high or prohibitive surgical risk underwent TMVI at our site. Three procedures were performed as TMVI in failed mitral valve bioprostheses (TMVI-VIV, "valve-in-valve"), one procedure was performed as TMVI in a failed mitral annuloplasty ring (TMVI-R), and three procedures were performed as TMVI in advanced native mitral annular calcification (TMVI-MAC). Mean age of the population treated was 77 ± 8.1 years, and mean log EuroScore I was 39 ± 0.12%. In all patients, an Edwards SAPIEN 3 transcatheter heart valve was implanted under 3D-TOE and fluoroscopic guidance using a transvenous/transseptal access. Indication for TMVI was the presence of advanced heart failure symptoms in all patients (NYHA class III/IV). The predominant dysfunction of the mitral valve treated was severe regurgitation in 72% (n = 5) and severe stenosis in 29% (n = 2) of all patients. TMVI was technically successful in all procedures. Clinical success with functional improvement of at least one NYHA class after procedure compared with before procedure was also achieved in all patients. Median NYHA class improved significantly from 4 before procedure to 2 after TMVI (p=0.008). Mitral valve regurgitation was reduced to trace or mild in all but one patient, who showed moderate MR after TMVI-MAC. No patient-prosthesis mismatch or LVOT obstruction occurred after TMVI. Two patients underwent interventional ASD closure during the in-hospital course due to a large and persisting atrial septal defect after transseptal access. One patient underwent pacemaker implantation due to complete AV-block after TMVI. One patient died in hospital 12 days after the procedure due to severe hospital-acquired pneumonia and sepsis. In-hospital mortality rate was 14% (1/7) in this high-risk population. After hospital discharge, no death occurred and clinical improvement-according to NYHA functional class-remained stable during one-year follow-up. CONCLUSION: In this small single-center series, TMVI appears promising for patients at high or prohibitive surgical risk with either failing mitral bioprostheses/annuloplasty rings or native mitral valve dysfunction in combination with advanced MAC. Gaining experience in TMVI and new valves will further improve safety and efficacy of this new treatment option.

Impact of left ventricular lead position on the incidence of ventricular arrhythmia and clinical outcome in patients with cardiac resynchronization therapy.

PURPOSE: The aim of the study was to evaluate the incidence of ventricular arrhythmia and clinical outcome in patients receiving a cardiac resynchronization therapy (CRT) depending on the left ventricular (LV) lead position. METHODS: A total of 187 consecutive patients with advanced heart failure who received a CRT-implantable cardioverter defibrillator were analyzed. Forty patients (21%) had a LV lead in the anterior/apical (anterior) and 147 patients (79%) in the posterior/posterolateral (posterior) region. The total median follow-up time was 644 days. RESULTS: The incidence of ventricular arrhythmia was 35% in patients with an anterior LV lead versus 30% in patients with a posterior LV lead (p = 0.53). The 1- and 2-year mortality in the anterior LV lead group was 19% and 22%, as compared with 0.7% and 3.2%, respectively, in the posterior LV lead group (p < 0.001). In a multivariable analysis, an anterior LV lead was independently associated with an increased mortality (hazard ratio 5.88, 95% confidence interval 2.22-16.67). The major cause of death was end-stage heart failure whereas the incidence of sudden cardiac death was not different between both groups. CONCLUSIONS: Thus, biventricular pacing with an anterior LV lead seems to have no impact on the incidence of ventricular arrhythmia but may be associated with an increased mortality rate due to worsening heart failure.

Prevalence of bacterial colonization of generator pockets in implantable cardioverter defibrillator patients without signs of infection undergoing generator replacement or lead revision.

AIMS: This study was designed to evaluate the prevalence of bacterial colonization of generator pockets in implantable cardioverter defibrillator (ICD) patients without signs of infection and to analyse the impact of bacterial colonization on the incidence of device infection during follow-up. METHODS AND RESULTS: In 122 ICD patients undergoing generator replacement or surgical lead revision between January 2006 and July 2008, microbiological cultures of generator pockets and extracted leads were consecutively obtained. Patients with clinical evidence of a device infection were excluded. Positive cultures from the generator pocket and leads were found in 40 (33%) patients. The most common bacteria isolated were coagulase negative staphylococci (68%). During a median follow-up time of 203 days after the revision device infection occurred in three [7.5%, confidence interval (CI) 1.6-20.4%] patients with a positive culture vs. two (2.4%, CI 0.3-8.5%) patients with a negative culture (P = 0.33). Time from revision to infection was 108 +/- 73 days in patients with positive culture vs. 60 +/- 39 days in patients with negative culture (P = 0.50). CONCLUSION: A third of ICD patients undergoing generator replacement or lead revision have an asymptomatic bacterial colonization of generator pockets. After revision 7.5% of these patients develop a device infection with the same species of microorganism.

Annual rate of transvenous defibrillation lead defects in implantable cardioverter-defibrillators over a period of >10 years.

BACKGROUND: The number of patients with longer follow-up after implantation of an implantable cardioverter-defibrillator is increasing continuously. Defibrillation lead failure is a typical long-term complication. Therefore, the long-term reliability of implantable cardioverter-defibrillator leads has become an increasing concern. The aim of the present study was to assess the annual rate of transvenous defibrillation lead defects related to follow-up time after lead implantation. METHODS AND RESULTS: A total of 990 consecutive patients who underwent first implantation of an implantable cardioverter-defibrillator between 1992 and May 2005 were analyzed. Median follow-up time was 934 days (interquartile range, 368 to 1870). Overall, 148 defibrillation leads (15%) failed during the follow-up. The estimated lead survival rates at 5 and 8 years after implantation were 85% and 60%, respectively. The annual failure rate increased progressively with time after implantation and reached 20% in 10-year-old leads (P<0.001). Lead defects affected newer as well as older models. Patients with lead defects were 3 years younger at implantation and more often female. Multiple lead implantation was associated with a trend to a higher rate of defibrillation lead defects (P=0.06). The major lead complications were insulation defects (56%), lead fractures (12%), loss of ventricular capture (11%), abnormal lead impedance (10%), and sensing failure (10%). CONCLUSIONS: An increasing annual lead failure rate is noted primarily during long-term follow-up and reached 20% in 10-year-old leads. Patients with lead defects are younger and more often female.

Advanced sternal closure to prevent dehiscence in obese patients.

Sternal dehiscence is a frequent complication after cardiac surgical procedures. The objective was to evaluate a novel method for advanced sternal closure compared with standard techniques for preventing sternal dehiscence. Our investigation comprised 100 patients with a body mass index above 32. Patients were randomly assigned to receive either advanced sternal closure with three stainless steel double wires or standard techniques with stainless steel single wires. The incidence of sternal refixation was 6 of 50 patients in the standard techniques group and 1 of 50 in the advanced sternal closure group during a follow-up period of 6 months.

Bispectral index in patients with target-controlled or manually-controlled infusion of propofol.

UNLABELLED: In this prospective, randomized study we compared bispectral index (BIS), hemodynamics, time to extubation, and the costs of target-controlled infusion (TCI) and manually-controlled infusion (MCI) of propofol. Forty patients undergoing first-time implantation of a cardioverter-defibrillator were included. Anesthesia was performed with remifentanil (0.2-0.3 micro g. kg(-1). min(-1)) and propofol. Propofol was used as TCI (plasma target concentration, 2.5-3.5 micro g/mL; n = 20) or MCI (3.0-4.0 mg. kg(-1). h(-1); n = 20). BIS, heart rate, and arterial blood pressure were measured at six data points: T1, before anesthesia; T2, after intubation; T3, after skin incision; T4, after first defibrillation; T5, after third defibrillation; and T6, after extubation. There were no significant hemodynamic differences between the two groups. BIS was significantly lower at T3 and T4 in the TCI group than in the MCI group. The mean dose of propofol was larger in TCI patients (5.8 +/- 1.4 mg. kg(-1). h(-1)) than in the MCI patients (3.7 +/- 0.6 mg. kg(-1). h(-1)) (P < 0.05), whereas doses of remifentanil did not differ. Time to extubation did not differ between the two groups (TCI, 13.7 +/- 5.3 min; MCI, 12.3 +/- 3.5 min). One patient in the MCI group had signs of intraoperative awareness without explicit memory after first defibrillation (BIS before shock, 49; after shock, 83). Costs were significantly less in the MCI group (34.83 US dollars) than in the TCI group (39.73 US dollars). BIS failed to predict the adequacy of anesthesia for the next painful stimulus. IMPLICATIONS: In this prospective, randomized study, bispectral index (BIS), hemodynamics, time to extubation, and costs of target-controlled infusion (TCI) and manually-controlled infusion of propofol were compared. TCI increased the amount of propofol used. BIS failed to predict the adequacy of anesthesia for the next painful stimulus.

Considerations in patients undergoing implantation of a biventricular pacemaker.

OBJECTIVE: To compare hemodynamics and oxygenation in patients with congestive heart failure and broad QRS complexes before and with biventricular DDD pacing and to report experience with this new procedure. DESIGN: Prospective, observational study. SETTING: Major university-affiliated community hospital. PARTICIPANTS: Ten patients with congestive heart failure (New York Heart Association III to IV) and broad QRS complexes (>160 msec). INTERVENTIONS: Patients underwent implantation of a biventricular pacemaker (n = 4) or implantation of a combined biventricular pacemaker and cardioverter-defibrillator (n = 6). Anesthesia was performed using remifentanil (0.2 to 0.3 microg/kg/min) and propofol. Propofol was used as target-controlled infusion (plasma target concentration, 1.5 to 2.5 microg/mL). MEASUREMENTS AND MAIN RESULTS: Hemodynamics and oxygenation were measured before and with biventricular DDD pacing. Mean arterial pressure was significantly increased from 64.7 +/- 5.8 mmHg to 77.8 +/- 10.6 mmHg by biventricular pacing, whereas cardiac index (2.2 +/- 0.3 L/min/m(2) before and 2.3 +/- 0.3 L/min/m(2) with biventricular pacing) and pulmonary capillary wedge pressure (12.1 +/- 3.8 mmHg before and 14.2 +/- 3.6 mmHg with biventricular pacing) remained unchanged. Left ventricular stroke work index was increased >10% in 7 patients. Oxygen delivery, oxygen consumption, and difference in arteriovenous oxygen concentration were not affected. Anesthesia with remifentanil and propofol was safe and well-controllable and allowed immediate extubation at the end of the operation. CONCLUSION: There was no acute intraoperative improvement of hemodynamics except increased mean arterial pressure with biventricular pacing. Left ventricular performance seemed to improve with biventricular pacing in some patients. These results might be due to a nonoptimized atrioventricular delay. Postoperatively, atrioventricular delay was individually programmed for each patient by Doppler transmitral flow patterns.

RETRACTED: Considerations in patients undergoing implantation of a biventricular pacemaker.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief, Dr. Joel Kaplan, based on the recommendations of Justus-Liebig-University Giessen following an internal review of research conducted by Joachim Boldt at this University and by following previous precedent such as the British Journal of Anaesthesia, as stated in 'Further Retractions of Articles by Joachim Boldt' https://doi.org/10.1016/j.bja.2020.02.024. The review by Justus-Liebig-University identified inconsistencies in data reported by Dr. Boldt and concluded, "JLU recommends that journal editors retract all papers where Dr. Boldt is the responsible author even if there is no obvious indication of falsification". The Editor-in-Chief has, therefore, made the decision to retract this paper. The journal contacted the corresponding author, J. Boldt, and authors A.L, and U.W, who did not respond. The journal was unable to contact authors J.L, E.T, and C.Z.