Corrigendum to "Regional variations in baseline characteristics of cardiac rhythm device recipients: The PANORAMA observational cohort study" [Int. J. Cardiol. Heart Vessels (2014) 90-96].

[This corrects the article DOI: 10.1016/j.ijchv.2014.06.008.].

Device-detected atrial fibrillation and risk for stroke: an analysis of >10,000 patients from the SOS AF project (Stroke preventiOn Strategies based on Atrial Fibrillation information from implanted devices).

OBJECTIVE: The aim of this study was to assess the association between maximum daily atrial fibrillation (AF) burden and risk of ischaemic stroke. BACKGROUND: Cardiac implanted electronic devices (CIEDs) enhance detection of AF, providing a comprehensive measure of AF burden. DESIGN, SETTING, AND PATIENTS: A pooled analysis of individual patient data from five prospective studies was performed. Patients without permanent AF, previously implanted with CIEDs, were included if they had at least 3 months of follow-up. A total of 10 016 patients (median age 70 years) met these criteria. The risk of ischaemic stroke associated with pre-specified cut-off points of AF burden (5 min, 1, 6, 12, and 23 h, respectively) was assessed. RESULTS: During a median follow-up of 24 months, 43% of 10 016 patients experienced at least 1 day with at least 5 min of AF burden and for them the median time to the maximum AF burden was 6 months (inter-quartile range: 1.3-14). A Cox regression analysis adjusted for the CHADS2 score and anticoagulants at baseline demonstrated that AF burden was an independent predictor of ischaemic stroke. Among the thresholds of AF burden that we evaluated, 1 h was associated with the highest hazard ratio (HR) for ischaemic stroke, i.e. 2.11 (95% CI: 1.22-3.64, P = 0.008). CONCLUSIONS: Device-detected AF burden is associated with an increased risk of ischaemic stroke in a relatively unselected population of CIEDs patients. This finding may add to the basis for timely and clinically appropriate decision-making on anticoagulation treatment.

Regional variations in baseline characteristics of cardiac rhythm device recipients: The PANORAMA observational cohort study.

BACKGROUND: The PANORAMA study was designed to collect concurrent data on subjects from different worldwide regions implanted with CRM devices. METHODS: In this prospective, multi-center study, we analyzed baseline data on 8586 subjects implanted with CRM devices with no additional selection criteria (66% pacemaker (IPG), 16% implantable cardiac defibrillators (ICD), 17% cardiac resynchronization therapy (CRT) and < 1% Internal Loop Recorder) from 156 hospitals across 6 geographical regions between 2005 and 2011. RESULTS: Regardless of the device implanted, subjects from the Middle East and India often had more diabetes than other regions. Eastern and Western Europe had higher rates of atrial fibrillation reported, and men were more likely to smoke than women (46% vs 11%, p < 0.001). Within the CRT cohort there was significant variation in the proportion of males receiving a device, ranging from 55% in India to 83% in Eastern Europe. CONCLUSIONS: We provide comprehensive descriptive data on patients receiving CRM devices from a range of geographies that are not typically reported in literature. We found significant variations in clinical characteristics and implant practices. Long term follow-up data will help evaluate if these variations require adjustments to outcome expectations.

A randomized open-label trial with a crossover comparison of sexual self-confidence and other treatment outcomes following tadalafil once a day vs. tadalafil or sildenafil on-demand in men with erectile dysfunction.

AIM: To compare Sexual Self-Confidence and other treatment outcomes following 8 weeks of treatment with tadalafil 5 mg once a day (OaD) vs. tadalafil 20 mg or sildenafil 100 mg as needed (pro re nata [PRN]) in patients with erectile dysfunction (ED). METHODS: A randomized, open-label, crossover study in men ≥18 years of age with history of ED and satisfactory response to current oral phosphodiesterase 5 (PDE5) inhibitor PRN. Data were analyzed with a mixed effects model for crossover design. MAIN OUTCOME MEASURES: The primary outcome measure was the Sexual Self-Confidence domain of the Psychological and Interpersonal Relationship Scales (PAIRS) between tadalafil OaD and sildenafil PRN. SECONDARY OUTCOMES INCLUDED: Time Concerns and Spontaneity domains of PAIRS, and the Self-Esteem and Relationship (SEAR) scale. RESULTS: Men naive to tadalafil OaD were enrolled (N = 378), with 61-69% prior PDE5 inhibitor use. There were improvements in all PAIRS domains from baseline when comparing tadalafil OaD and PRN with sildenafil PRN (P < 0.001). The Sexual Self-Confidence domain improved from baseline and was 0.50 ± 0.78 following tadalafil OaD, 0.5 ± 0.72 for tadalafil PRN, and 0.39 ± 0.67 for sildenafil PRN. The difference in least-squares mean was 0.12 ± 0.04 (confidence interval [CI] = 0.04, 0.19; P = 0.001) between tadalafil OaD and sildenafil PRN and 0.01 ± 0.04 (CI = -0.06, 0.08; P = 0.872) between tadalafil OaD and tadalafil PRN. The Time Concerns domain score was lower with tadalafil OaD than tadalafil PRN (P < 0.001). There were no differences in SEAR scores between treatments. CONCLUSIONS: Tadalafil OaD and tadalafil PRN compared with sildenafil PRN demonstrated greater improvements in Sexual Self-Confidence, Time Concerns, and Spontaneity. There was no significant difference in Sexual Self-Confidence between tadalafil OaD and tadalafil PRN. Changes in SEAR, the erectile function domain of the International Index of Erectile Function, and the Erectile Dysfunction Inventory of Treatment Satisfaction scores from baseline to end point were similar.

Stimulation of the intra-cardiac vagal nerves innervating the AV-node to control ventricular rate during AF: specificity, parameter optimization and chronic use up to 3 months.

BACKGROUND: Stimulation of the intra-cardiac vagal nerves innervating the AV-node (AVNS) is a promising approach to slow down ventricular rate (VR) during atrial fibrillation (AF). Our purpose was to demonstrate that effects on R-R-interval during stable AF can be maintained for several months once optimized and that AVNS affects specifically the nerves innervating the AV-node. METHODS: Our study included both an acute and chronic phase. Fifteen goats were implanted with a pacemaker connected to an atrial and ventricular lead and a neurostimulator connected to an atrial lead placed at a certain septal site, to induce an AV prolongation. In the chronic experiments (n = 9), after assessment of optimal AVNS parameters, the effect of continuous AVNS on VR was studied during stable AF for up to 3 months. The mechanism of AVNS was studied using atropine and esmolol. Next, the effects of AVNS during the atrial refractory period on electrophysiological and hemodynamic parameters were investigated acutely (n = 7). RESULTS: The maximal effect was found at a stimulation frequency of 40 Hz, and increased with increasing pulse width (at lower voltages) and increasing voltage. After 0, 1, and 3 months of AVNS during stable AF, AVNS decreased average VR, respectively, 55% (n = 9), 48% (n = 8), and 28% (n = 6). The AVNS effect appeared to be dominantly parasympathetic. AVNS did not influence (1) the sinus node, (2) the refractory period of the atrial, ventricular tissue, and His and (3) hemodynamic parameters. CONCLUSION: AVNS is efficient in reducing ventricular rate for at least 3 months using optimized parameters and specifically affects the parasympathetic nerves innervating the AV-node.

Timing of dose relative to sexual intercourse attempt in previous sildenafil citrate users treated with tadalafil: a geographical comparison from a single arm, open-label study.

INTRODUCTION: Previous research has demonstrated that sildenafil citrate users alter dosing-sexual attempt behavior when switched to tadalafil. The impact of geography and culture on sexual behavior with phosphodiesterase type 5 (PDE5) inhibitor treatment has not been fully investigated. AIM: To describe and compare the changes in dosing-sexual attempt behavior with sildenafil citrate vs. tadalafil treatment across four distinct geographies: Asia, Australia/New Zealand (ANZ), Central Eastern Europe/Middle East (CEE/ME), and Latin America (LA). METHODS: Data from a single-arm, open-label clinical trial conducted in 21 countries from November 2002 to May 2004 were used in this analysis. Men with erectile dysfunction and a history of > or =6-week prior sildenafil citrate use continued sildenafil citrate treatment for 4 weeks then switched to tadalafil for 8 weeks. Dosing instructions were provided. MAIN OUTCOMES MEASURES: Timing of dose and sexual intercourse was assessed through patient diaries for the final 4 weeks of each treatment period. RESULTS: A total of 2,760 men were enrolled: Asia 15.8%; ANZ 29.4%; CEE/ME 19.7%; LA 35.1%. The median time from dosing to intercourse was significantly increased during tadalafil treatment across all geographical regions; however, the magnitude of increase differed significantly by geography (P < 0.0001). The Asian cohort demonstrated the shortest duration between dosing and sexual intercourse attempts (irrespective of drug), and altered sexual behavior the least upon switching to tadalafil. The ANZ cohort demonstrated the longest duration between dosing and sexual intercourse attempts (irrespective of drug), and altered sexual behavior the most upon switching to tadalafil. CONCLUSION: Men with a history of established sildenafil citrate use alter their dose-attempt behavior when treated with tadalafil irrespective of geography. However, the extent to which sexual behavior alters is not uniform across geographical regions, suggesting that dosing instructions and duration of drug effectiveness, in combination with personal and cultural preferences, may determine sexual behavior with PDE5 inhibitor use.

Patient attitudes towards chemotherapy and survival: a prospective observational study in advanced non-small cell lung cancer.

This multicenter, non-interventional, prospective, observational study aimed to determine whether patients' attitude to chemotherapy is an independent prognostic factor for survival in patients with advanced non-small cell lung cancer (NSCLC) who are treated with gemcitabine-platinum. Chemonaive patients (n=1895) with stage IIIB or IV NSCLC not amenable to curative surgery or radiotherapy were treated with a combination of gemcitabine plus cisplatin/carboplatin and followed for a maximum of 18 months. Patients' attitude to treatment was measured on a 5-point scale and responses were used to assign patients to one of the three need categories: A, maximum extension of survival with the acceptance of high toxicity (60.0% of patients); B, maximum extension of survival only if coupled with normal lifestyle (26.1%); C, relief of symptoms (13.8%). Median survival varied significantly among the need categories (A=13.00 months, B=15.70 months, C=15.33 months; log-rank test P=0.0415). Patient attitude to treatment (need categories) was not a significant prognostic factor for survival after adjusting for known prognostic factors (P=0.0503). After adjusting for baseline differences, patients in this study had a significantly lower risk of death than patients in three randomized trials (hazard ratio 0.879; 95% confidence interval: 0.775, 0.998; P=0.0458). In conclusion, in this observational study, patient attitude to chemotherapy was not an independent prognostic factor of survival.

Long-term antipsychotic monotherapy for schizophrenia: disease burden and comparative outcomes for patients treated with olanzapine, quetiapine, risperidone, or haloperidol monotherapy in a pan-continental observational study.

OBJECTIVE: Noninterventional, naturalistic studies facilitate examination of current clinical practices and provide an understanding of the impact of the biopsychosocial aspects of schizophrenia. This article describes disease burden and patient outcomes, with an emphasis on the comparative effectiveness and tolerability of antipsychotic monotherapy. METHOD: Outpatients initiating or changing antipsychotic therapy for DSM-IV- or ICD-10-defined schizophrenia (N = 7658) were allocated to olanzapine or nonolanzapine cohorts (November 2000 to December 2001). Treatment was at the psychiatrist's discretion, including flexible dosing and use of concomitant therapies and medications, with assessments at 0, 3, 6, 12, 18, 24, 30, and 36 months. Longitudinal clinical, pharmacologic, functional, and social data were collected over 36 months across 27 countries. RESULTS: At entry, 76% of patients were initiated/switched to antipsychotic monotherapy, most commonly with olanzapine (N = 3222), risperidone (N = 1117), quetiapine (N = 189), or haloperidol (N = 257). Patients prescribed olanzapine were more likely to maintain their baseline monotherapy (p < .001) and did so for a longer period (p < .001) compared with other antipsychotics. Median time to discontinuation (in months) was as follows: olanzapine 30.0, risperidone 23.1, quetiapine 13.9, haloperidol 12.5. Olanzapine-treated patients were also more likely to respond, and did so more rapidly than patients on other monotherapies (p < .001). Response data were also favorable for risperidone; median time to response (in months) was as follows: olanzapine 5.2, risperidone 6.3, quetiapine 11.3, haloperidol 11.7. Treatment-emergent adverse events varied: olanzapine patients had less favorable odds for significant weight gain (p < .001); haloperidol patients, for motor dysfunction (p < or = .002). CONCLUSION: These naturalistic data from less-studied outpatient communities highlight the variability in clinical and functional outcomes associated with long-term antipsychotic treatment.

Gemcitabine and cisplatin treatment over a 3-week versus a 4-week dosing schedule: a randomized trial conducted in Chinese patients with nonsmall cell lung cancer.

BACKGROUND: Gemcitabine plus cisplatin is a standard treatment for stages IIIB and IV nonsmall cell lung cancer (NSCLC). This randomized phase II study evaluated a 3-week versus a 4-week schedule of gemcitabine-cisplatin as first line treatment for Chinese patients with advanced NSCLC. METHODS: Patients were randomized to receive cisplatin 75 mg/m(2) on day 1 plus either gemcitabine 1250 mg/m(2) on days 1 and 8 of a 21-day cycle (3-week group) or gemcitabine 1000 mg/m(2) on days 1, 8 and 15 of a 28-day cycle (4-week group). RESULTS: One hundred patients were enrolled in this study. The response rate was 24% (12/51 patients) in the 3-week group and 27% (13/49 patients) in the 4-week group. There were no statistically significant differences between the two treatment groups in survival (hazard ratio: 1.19; 95% CI: 0.68 - 2.09) with a median survival of 12.1 months and 13.8 months in the 3-week group and the 4-week group respectively. The rate of grade 3/4 toxicity in the 3-week group was 55% compared with 86% in the 4-week group (P = 0.001). The difference in the incidence of grade 3/4 haematological toxicities did not reach statistical significance (3-week: 37%, 4-week: 57%), however grade 3/4 drug related neutropenia (3-week: 27%, 4-week: 51%) and thrombocytopenia (3-week: 8%, 4-week: 31%) were significantly lower in the 3-week group. Grade 3/4 nonhaematological toxicities were less in the 3-week group (33% cf 63%; P = 0.005). CONCLUSIONS: The differences in the efficacy endpoints were all in favour of the 4-week schedule of gemcitabine plus cisplatin, however these differences did not reach statistical significance. Fewer grade 3/4 toxicities were observed in the 3-week group compared with the 4-week group.

Cardiac outcome up to 15 years after the arterial switch operation.

AIMS: To assess the cardiac outcome and risk factors for mortality of infants following the arterial switch operation (ASO). METHODS: A single-centre retrospective review was conducted. Preoperative assessment, operative management and outcome was detailed for 244 patients undergoing the ASO at Green Lane Hospital for transposition of the great arteries (TGA) or double outlet right ventricle. RESULTS: The postoperative survival at 1, 5 and 15 years was 85%, 84% and 83%, respectively. The calendar year of ASO and the presence of a ventricular septal defect (VSD) were the primary predictors of early mortality. Late mortality was associated with a side-by-side configuration of the great arteries. Re-intervention following ASO was more common in patients with prolonged cardiopulmonary bypass time. CONCLUSIONS: Low early and late morbidity and mortality can be obtained in infants with TGA or double outlet right ventricle by definitive repair utilising the ASO.

Distal embolization during native vessel and vein graft coronary intervention with a vascular protection device: predictors of high-risk lesions.

OBJECTIVE: We sought to define clinical and angiographic variables that may predict patients and lesions at increased risk for distal embolism during percutaneous intervention (PCI), as assessed by debris retrieval from a distal-protection filter device. BACKGROUND: Distal thrombo- and atheroembolism may contribute to periprocedural myocardial necrosis during PCI, which may in turn affect long-term outcomes. Distal protection devices have been used to reduce this occurrence with variable outcomes depending on lesion and patient subsets. METHODS: 194 consecutive patients in whom the FilterWire(R) device (FW) [Boston Scientific Corp., Natick, MA] was used for native coronary vessel (n =129) or vein graft (n = 65) PCI were studied. FW debris was visually analyzed using a semi-quantitative grading score. Patients with "significant" debris (particles > or = 1 mm diameter) were compared with those with "nonsignificant" debris (no debris or particles <1 mm) with respect to clinical (age, gender, coronary disease risk factors, clinical presentation, periprocedural medications), and angiographic (vessel treated, vessel size, lesion length, lesion characteristics, angiographic thrombus and TIMI flow before and after PCI) variables. RESULTS: Significant debris was retrieved in 55% of patients, more frequently from vein graft (69%) than native vessel lesions (48%, p = 0.006). No clinical characteristics predicted significant debris retrieval. Angiographic predictors of significant debris by multivariate analysis were longer stent length and final TIMI flow <3 (p = 0.009 and 0.007, respectively). CONCLUSION: Longer stent length, likely reflecting increased lesion length and plaque burden, predicted significant distal embolism during PCI in native vessel and vein graft lesions, as assessed by debris collected in a distal vascular protection device. This suggests that use of vascular protection devices should be considered during PCI of long lesions.

Gemcitabine administered as a short infusion versus a fixed dose rate in combination with cisplatin for the treatment of patients with advanced non-small cell lung cancer.

Previous studies have indicated that, in combination with cisplatin, fixed dose rate gemcitabine may be more efficacious than standard infusion gemcitabine. This open-label, randomised phase II study was aimed to compare the efficacy and safety of these regimens as treatment for advanced non-small cell lung cancer (NSCLC) in Latin American patients. Sixty-four patients were randomised to receive up to six cycles of treatment with cisplatin 75 mg/m(2) on Day 1 plus either gemcitabine 1000 mg/m(2) over 30 min on Days 1 and 8 of a 21-day cycle (standard arm, N=33) or gemcitabine 1000 mg/m(2) at a fixed dose rate of 10 mg/m(2)/min on Days 1 and 8 of a 21-day cycle (FDR arm, N=31). In the standard arm, 9 of 33 (27%) patients responded compared with 6 of 30 (20%) patients in the FDR arm (odds ratio: 0.67, 95% CI, 0.21-2.2; p=0.56). Median overall survival was 7.5 months in the standard arm and 9.9 months in the FDR arm. One-year survival rates were 35% and 37% in the standard arm and the FDR arm, respectively. Patients in the FDR arm experienced more grade 3/4 haematological toxicity than those in the standard arm (48% versus 21%). The results of this trial do not support FDR administration of gemcitabine in preference to the standard administration in Latin American patients with NSCLC.

Antiplatelet therapy and progression of coronary artery disease: a placebo-controlled trial with angiographic and clinical follow-up after myocardial infarction.

INTRODUCTION: In patients after ST-elevation myocardial infarction (STEMI), antiplatelet therapy reduces subsequent cardiac events, which are often attributed to recurrent thrombosis with (sub)total occlusion in the infarct-related artery. Whether antiplatelet therapy influences the often subclinical process of coronary disease progression in noninfarct arteries has not been reported. METHODS: Quantitative coronary angiography of noninfarct arteries was performed on paired cine-angiograms of 149 patients from fibrinolytic trials who had a patent infarct-related artery 3 to 4 weeks following STEMI and who were randomized to either continue the daily combination of 50-mg aspirin and 400-mg dipyridamole or to matching placebo. Follow-up angiography was scheduled at 1 year. RESULTS: On a per-patient basis, the change in minimal luminal diameter (MLD) was 0.00 mm in the aspirin/dipyridamole group (n = 76) and was 0.01 mm in the placebo group (n = 73). There was no difference between these groups in the changes in MLD (-0.02 mm; 95% CI -0.09 to 0.05), neither were there significant differences in mean luminal diameter and diameter stenosis. Progression (1 segment/patient with > or = 0.40 mm decrease in MLD) was seen in two thirds of patients and did not independently predict long-term death and/or reinfarction. CONCLUSION: In this placebo-controlled trial after STEMI, the combination of aspirin and dipyridamole did not affect noninfarct artery disease progression. Progression did not predict long-term clinical outcome.

Surgery for acute type a aortic dissection a 37-year experience in Green Lane Hospital.

PURPOSE: To review the management of patients with acute type A aortic dissection. METHODS: Between June 1967 and December 2003, 246 patients (151 males and 95 females, 20-82 years; median 59 years) underwent operation for type A dissection. Early mortality and aortic dissection-related late events (reoperation and death related to aortic dissection) were assessed and correlated with the surgical approach. RESULTS: Over 37 years, early mortality has markedly improved, 50% in 1970s, 22% in 1980s, 17% in 1990s, and 11% after 2000. However, late deaths occurred at a constant rate, overall late survival at 10 and 20 years were 59% and 9%, respectively, and this did not improve after the 1990s. Preoperative hemodynamic instability, myocardial and kidney malperfusion, smoking history, prolonged bypass and cross-clamp time, and year of surgery were found to be risk factors for early death. The main cause (21%) of late deaths was aortic dissection-related events, especially in the distal aorta. However, no intraoperative risk factors were found to be predictive of late dissection-related events. Surgical techniques including complete resection of the intimal tear or distal extent of the surgery had no impact on late distal event-free survival. CONCLUSION: Despite improvement of short-term outcome over 37 years, patients who had aortic dissection are still living with elevated risk of death. Although late events in the distal aorta were a major risk, aggressive surgical approaches did not improve these outcomes. Vigilant follow-up is necessary for these patients.

A prospective randomised single blinded study comparing harmonic scalpel tonsillectomy with bipolar tonsillectomy.

OBJECTIVE: To compare the differences in pain, analgesic use and bleeding in children after tonsillectomy using either a harmonic scalpel or a bipolar diathermy surgical technique. METHODS: Children 6-15 years presenting for tonsillectomy were randomised to either a harmonic scalpel or bipolar diathermy surgical technique. Post-operative pain scores (VAS, 0-10) were recorded within 30 min of surgery and again at the 4h hospital discharge. A subsequent telephone interview daily for 7 days and then every second day until day 13 was used to monitor pain scores, analgesic use and tonsil bed bleeding. RESULTS: There were 204 children studied. The response rate over the first 7 days was 93% for the children in the harmonic scalpel group and 87% for the bipolar group. Children experienced moderate post-operative pain for the first 6 days, after which pain declined from 4-7 to reach a score of 1-2 by day 11. Children undergoing harmonic scalpel tonsillectomy (n=103) reported higher mean pain scores than those who underwent bipolar diathermy (n=101) for current pain (4.7 versus 4.2, p=0.002), worst pain of the day (6.9 versus 6.2, p<0.001) and pain on swallowing (5.9 versus 5.2, p<0.001) over the first 6 post-operative days. Analgesic use (acetaminophen, ibuprofen) was similar in both groups. Hospital readmission for bleeding in children who underwent harmonic scalpel was similar to those who underwent bipolar diathermy tonsillectomy (9% versus 11%) as was bleeding requiring surgical re-exploration (4% versus 2%). CONCLUSIONS: Tonsillectomy was associated with considerable pain for the first 6 post-operative days. Children undergoing harmonic scalpel tonsillectomy had a slight increase in pain compared to the bipolar diathermy group during this time. Both methods of tonsillectomy are effective and safe.

Extra-aortic balloon counterpulsation: an intraoperative feasibility study.

BACKGROUND: Current methods of counterpulsation or ventricular assistance have significant vascular and limb complications. The aim of this study was to determine the safety and performance of a new method of non-blood-contacting counterpulsation using an inflatable cuff around the ascending aorta (extra-aortic balloon [EAB]). METHODS AND RESULTS: In 6 patients undergoing first time off-pump coronary bypass surgery via sternotomy, the EAB was secured around the ascending aorta and attached to a standard counterpulsation console. At baseline and with 1:2 and 1:1 augmentation, hemodynamic and echocardiographic parameters of ventricular function and coronary flow were measured. High-intensity transient signals were measured using transcutaneous Doppler over the right common carotid artery. No complications occurred. With EAB there was no significant change in heart rate or blood pressure and no increase in high-intensity transient signals. There was a 67% increase in diastolic coronary blood flow (mean left-main diastolic velocity time integral 15.3 cm unassisted versus 25.1 cm assisted, P<0.05). Measurements with transesophageal echocardiography at baseline and with 1:1 counterpulsation demonstrated a 6% reduction in end-diastolic area (P=NS), a 16% reduction in end-systolic area (P<0.01), a 31% reduction in left ventricular wall stress (P<0.05), and a 13% improvement in fractional area change (P<0.005). CONCLUSIONS: EAB counterpulsation augments coronary flow and reduces left ventricular afterload. Further testing is warranted to assess the use of the EAB for chronic non-blood-contacting support of the failing heart.

Bacteriological outcome after valve surgery for active infective endocarditis: implications for duration of treatment after surgery.

BACKGROUND: There has been no systematic evaluation of outcome after surgery for infective endocarditis with respect to duration of antibiotic treatment. METHODS: We performed a retrospective chart review of episodes of valve surgery for active infective endocarditis at Green Lane Hospital (Auckland, New Zealand) for 1963-1999. We recorded the duration of antibiotic treatment before and after valve surgery; the extent of infection at operation; Gram stain, culture, and histopathological testing results for valve samples; and the bacteriological outcome after surgery. The primary outcome measure was relapse, defined as endocarditis due to the same species within 1 year after surgery. RESULTS: For the 358 patients in our study, the median duration of follow-up was 4.8 years. Thirty-two patients (9%) had 36 subsequent episodes of endocarditis. Relapse occurred after 3 (0.8%) of the operations (95% CI, 0.2%-2.0%). Relapse of infection was unrelated to the duration of antibiotic treatment before or after surgery, positive valve culture results, positive Gram stain results, or perivalvular infection. Since 1994, we have reduced the duration of antibiotic treatment by approximately 7 days for those with positive valve culture results and by approximately 14 days for those with negative valve culture results, without any increase in the number of relapses. CONCLUSIONS: Relapse is an uncommon event following surgery for endocarditis. Commonly suggested indications for prolonging postoperative treatment are not associated with higher relapse rates, and their relevance is debatable. We conclude that it is unnecessary to continue treatment for patients with negative valve culture results for an arbitrary 4-6-week period after surgery. Two weeks of treatment appears to be sufficient, and, for those operated on near the end of the standard period of treatment, simply completing the planned course should suffice.

Usefulness of serial measurement of N-terminal pro-brain natriuretic peptide plasma levels in asymptomatic patients with aortic stenosis to predict symptomatic deterioration.

In 29 initially asymptomatic patients with aortic stenosis followed for an average of 18 months, patients with a N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level above the normal range at baseline were more likely to develop symptoms during follow-up compared with patients with NT-pro-BNP within normal limits. The average increase in NT-pro-BNP per year was greater for patients who developed symptoms compared with patients who remained asymptomatic. Aortic valve area, peak aortic velocity, and the ejection fraction were less reliable predictors of symptom onset. Measurement of NT-pro-BNP in addition to clinical assessment and echocardiography may allow more reliable follow-up and timing of valve replacement for aortic stenosis.

Culture results of heart valves resected because of streptococcal endocarditis: insights into duration of treatment to achieve valve sterilization.

OBJECTIVES: To analyse the culture results of heart valves removed following streptococcal endocarditis in order to gain insight into the duration of treatment required for valve sterilization. PATIENTS AND METHODS: Retrospective review of 131 episodes of streptococcal endocarditis: 94 due to alpha-haemolytic streptococci; 15 due to beta-haemolytic streptococci; 10 due to nutritionally deficient streptococci; eight due to the Streptococcus anginosus group and four due to Streptococcus pneumoniae. Patients had their valves removed during antimicrobial treatment. Culture results were analysed with respect to duration of treatment before surgery. RESULTS: For alpha-haemolytic streptococci, 17 (18%) valves were culture-positive and 77 (82%) culture-negative after a median (range) of 4 (1-20) and 16 (4-58) days of treatment, respectively, P < 0.001. For beta-haemolytic streptococci, two valves (13%) were culture-positive; both patients had received < or = 4 days of treatment. Four patients (40%) with nutritionally deficient streptococci were culture-positive, and had received < or = 8 days of treatment. For the S. anginosus group, two valves (25%) were culture-positive; both patients had received < or = 4 days of treatment before operation. Overall, only one of 131 (0.8%) valves was culture-positive after 14 days of treatment. All valves infected with beta-haemolytic streptococci, nutritionally deficient streptococci and the S. anginosus group, who were treated for more than 8 days before surgery, were culture-negative. CONCLUSIONS: Our findings support current treatment guidelines for endocarditis caused by alpha-haemolytic streptococci. We suggest that the recommended duration of treatment for endocarditis resulting from other streptococci may be excessive and treatment trials evaluating 2 and 4 week regimens are justified.