Massive purulent pericarditis presenting as cardiac tamponade.

Acute bacterial pericarditis is rarely encountered in the modern antibiotic era. Purulent pericarditis is a serious form of bacterial pericarditis with high mortality. It can rapidly progress to cardiac tamponade, leading to hemodynamic instability, septic shock, and death if left untreated. Here we present a case of massive purulent pericarditis with cardiac tamponade that was successfully managed with intravenous antibiotics and drainage in a young immunocompetent man.

Role of statins in delirium prevention in critical ill and cardiac surgery patients: A systematic review and meta-analysis.

BACKGROUND: The data evaluating the role of statins in delirium prevention in the intensive care unit are conflicting and limited. METHODS: We performed a systematic review and meta-analysis of literature from 1975 to 2015. All English-language adult studies evaluating delirium incidence in statin and statin nonusers were included and studies without a control group were excluded. Mantel-Haenszel model was used to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). Statistical significance was defined as CI not including unity and P value less than .05. RESULTS: Of a total 57 identified studies, 6 were included. The studies showed high heterogeneity (I2 = 73%) for all and moderate for cardiac surgery studies (I2 = 55%). Of 289 773 patients, statins were used in 22 292 (7.7%). Cardiac surgery was performed in 4382 (1.5%) patients and 2321 (53.0%) used statins. Delirium was noted in 710 (3.2%) and 3478 (1.3%) of the patients in the statin and nonstatin groups, respectively, with no difference between groups in the total cohort (RR, 1.05 [95% CI, 0.85-1.29]; P = .56) or in cardiac surgery patients (RR, 1.03 [95% CI, 0.68-1.56]; P = .89). CONCLUSIONS: In critically ill and cardiac surgery patients, this meta-analysis did not show a benefit with statin therapy in the prevention of delirium.

Tricuspid and mitral endocarditis due to methicillin-resistant Staphylococcus aureus exhibiting vancomycin-creep phenomenon.

Right-sided infective endocarditis (RIE) is commonly due to Staphylococcus aureus and often involves the tricuspid valve (TV). A 31-year-old man with prior intravenous drug use presented with substernal pain, cough, dyspnoea and fever. Examination revealed a febrile, tachycardic male with peripheral infective endocarditis stigmata and right-heart failure. Laboratory parameters demonstrated leucocytosis, lactic acidosis and methicillin-resistant S. aureus (MRSA) bacteraemia. Echocardiography demonstrated multiple TV echodensities and chest imaging confirmed septic emboli. The MRSA species demonstrated 'vancomycin-creep', necessitating therapy with daptomycin and ceftaroline. Owing to persistent bacteraemia and septic shock, the patient underwent TV surgery, but continued to have a poor postoperative course with subsequent death. Indications for surgical therapy of RIE are limited to the European guidelines and most data are extrapolated from left-heart disease. MRSA exhibiting vancomycin-creep portends a poorer prognosis and requires aggressive therapy. We advocate the use of ceftaroline salvage therapy with daptomycin, pending further trials.

Efficacy and safety of transulnar coronary angiography and interventions--a single center experience.

OBJECTIVES: To evaluate the efficacy and long-term safety of transulnar approach in complex coronary interventions. BACKGROUND: The success rate of transulnar approach in complex coronary interventions and its long-term safety remains to be proven. METHODS: We conducted a retrospective chart review of patients undergoing transulnar coronary angiography and interventions at our institution from January 2004 through July 2009. Primary endpoint of the study was the success rate of the procedure. Secondary endpoints were major bleeding, local vascular and neurological complications, cerebrovascular accident (CVA)/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE) rate that was a composite of MI, CVA/TIA, and all-cause mortality. RESULTS: Of 81 patients undergoing transulnar approach, 41 (50.6%) patients underwent intervention on 65 lesions. Twelve percent of the interventions were performed on coronary bypass grafts and 9.2% on the left main coronary artery. Success rates for transulnar access, coronary angiography, and coronary/bypass graft interventions were 93.8%, 100%, and 92.6%, respectively. Follow-up data was available on 71 patients at short term (30 days) and 58 patients at long term (1 year). At 30-day follow-up, vascular complication rate was 2.8 %. At 1-year follow-up, there were no residual deficits from vascular or neurological complications associated with the index procedure and the overall MACE rate was 3.4%. CONCLUSION: In this first study evaluating long-term safety and feasibility of transulnar coronary angiography and complex coronary interventions, we conclude that transulnar approach appears to be safe and effective.

Effect of carvedilol versus metoprolol CR/XL on mortality in patients with heart failure treated with cardiac resynchronization therapy: a COX multivariate regression analysis.

We investigated in 136 consecutive patients with heart failure receiving cardiac resynchronization therapy (CRT) the effect of carvedilol versus metoprolol CR/XL versus no beta blocker on mortality. Of the 136 patients, 42 (31%) were on carvedilol, 80 (59%) were on metoprolol CR/XL, and 14 (10%) were not on a beta blocker. A decrease of left ventricular end-systolic volume ≥15% after CRT was defined as a positive response to CRT. Of the 136 patients, 62 (46%) responded to CRT. It was found that both carvedilol and metoprolol CR/XL were not related to CRT response on using Cox univariate regression analysis. Twenty-two of the 136 patients (16%) died during follow-up of 17 ± 10 months after initiating CRT. Mortality occurred in 14 of 80 patients (18%) on metoprolol CR/XL, in 3 of 42 patients (7%) on carvedilol, and in 5 of 14 patients (36%) not on beta blockers (P = 0.04). After adjustment for age, gender, and the variables with significant differences by Cox univariate regression, both carvedilol (hazard ratio = 0.14; P = 0.03; 95% confidence interval = 0.02-0.86) and metoprolol CR/XL (hazard ratio = 0.19; P = 0.02; 95% confidence interval = 0.04-0.80) were found to be related to mortality by Cox multivariate regression.

Coronary artery ectasia: current concepts and interventions.

Coronary artery ectasia (CAE) is a well-recognized angiographic finding, characterized by abnormal dilatation of the coronary arteries. We reviewed the current concepts of the condition including etiology, pathogenesis, flow alterations, clinical implications, prognosis and treatment. CAE is often viewed as a variant of obstructive coronary atherosclerosis. Exaggerated positive vascular remodeling due to inflammation, and chronic overstimulation of the endothelium by nitric oxide are potential causative mechanisms. The condition is associated with cardiovascular risk factors such as smoking and hypertension, while it appears to be inversely associated with age and diabetes mellitus. Patients with CAE typically present with angina, and are at risk for myocardial infarctions and sudden cardiac death due to slow flow, coronary vasospasm, dissection, and/or intracoronary thrombosis. CAE may be a diffuse disease associated with dilatation in other parts of the vasculature. As the incidence of this not so benign condition is expected to rise, the optimal treatment options remain undefined. Medical therapy with anticoagulants, nitrates and calcium channel blockers has been proposed and seems rational; however prospective studies with proof of efficacy are needed.

Development and validation of a risk calculator for prediction of cardiac risk after surgery.

BACKGROUND: Perioperative myocardial infarction or cardiac arrest is associated with significant morbidity and mortality. The Revised Cardiac Risk Index is currently the most commonly used cardiac risk stratification tool; however, it has several limitations, one of which is its relatively low discriminative ability. The objective of the present study was to develop and validate a predictive cardiac risk calculator. METHODS AND RESULTS: Patients who underwent surgery were identified from the American College of Surgeons' 2007 National Surgical Quality Improvement Program database, a multicenter (>250 hospitals) prospective database. Of the 211 410 patients, 1371 (0.65%) developed perioperative myocardial infarction or cardiac arrest. On multivariate logistic regression analysis, 5 predictors of perioperative myocardial infarction or cardiac arrest were identified: type of surgery, dependent functional status, abnormal creatinine, American Society of Anesthesiologists' class, and increasing age. The risk model based on the 2007 data set was subsequently validated on the 2008 data set (n=257 385). The model performance was very similar between the 2007 and 2008 data sets, with C statistics (also known as area under the receiver operating characteristic curve) of 0.884 and 0.874, respectively. Application of the Revised Cardiac Risk Index to the 2008 National Surgical Quality Improvement Program data set yielded a relatively lower C statistic (0.747). The risk model was used to develop an interactive risk calculator. CONCLUSIONS: The cardiac risk calculator provides a risk estimate of perioperative myocardial infarction or cardiac arrest and is anticipated to simplify the informed consent process. Its predictive performance surpasses that of the Revised Cardiac Risk Index.

Outcomes after carotid artery stenting and endarterectomy in the Medicare population.

BACKGROUND AND PURPOSE: Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for stroke prevention. The value of this therapy relative to CEA remains uncertain. METHODS: In 10 958 Medicare patients aged 66 years or older between 2004 and 2006, we analyzed in-hospital, 1-year stroke, myocardial infarction, and death rate outcomes and the effects of potential confounding variables. RESULTS: CAS patients (87% were asymptomatic) had a higher baseline risk profile, including having a higher percentage of coronary and peripheral arterial disease, heart failure, and renal failure. In-hospital stroke rate (1.9% CAS versus 1.4% CEA; P=0.14) and mortality (CAS 0.9% versus 0.6% CEA; P=0.20) were similar. By 1 year, CAS patients had similar stroke rates (5.3% CAS versus 4.1% CEA; P=0.12) but higher all-cause mortality rates (9.9% CAS versus 6.1% CEA; P<0.001). Using Cox multivariable models, there was a similar stroke risk (hazard ratio, 1.28; 95% CI, 0.90-1.79) but CAS patients had a significantly higher mortality (HR, 1.32; 95% CI, 1.02-1.71). Sensitivity analyses suggested that unmeasured confounders could be responsible for the mortality difference. In multivariable analysis, stroke risk was highest in the patients symptomatic at the time of revascularization. CONCLUSIONS: CAS patients had a similar stroke risk but an increased mortality rate at 1 year compared with CEA patients, possibly related to the higher baseline risk profile in the CAS patient group.

Primary cardiac angiosarcoma: in a patient with a dacron aortic prosthesis.

This is a report of a primary cardiac angiosarcoma in a woman who, several years earlier, had undergone repair of an aortic dissection with a Dacron graft prosthesis. Dacron prostheses have rarely been associated with neoplasia, and this, to our knowledge, is the first reported case of primary cardiac angiosarcoma in association with Dacron. Our patient presented with extensive metastases. If tumors are localized, they can be treated successfully with a combination of surgical resection, chemotherapy, and radiotherapy. Cardiac transplantation can also be beneficial, but the overall prognosis remains poor.

A patient selection score for cardiac resynchronization therapy.

BACKGROUND: We hypothesized a patient selection score (PSS) may improve patient selection for cardiac resynchronization therapy (CRT). METHODS: Of 136 patients who received CRT, group A included 100 study patients and group B 36 patients for validation. A positive response to CRT was a left ventricular (LV) end-systolic volume decrease of ≥15% and survival from heart failure at end of follow-up. RESULTS: Of 100 group A patients, 37 (37%) were CRT responders during 14-month follow-up. A 7-point PSS was generated based on six variables. The cutoff point for PSS to predict a positive response to CRT was >4 by receiver operating characteristic (ROC) analysis. The area under the ROC curve (AUC) for PSS to predict CRT response was 0.94 (P = 0.0001). CRT responders in patients with a PSS > 4 and ≤4 were 33/40 (83%), and 4/60 (7%), respectively (P < 0.001). Multivariate Cox proportional regression analysis showed that PSS was related to CRT response (hazard ratio = 10.3, P < 0.0001). The CRT response rate in patients with a PSS > 4 in Group B was also significantly higher compared to a PSS ≤ 4 (88% vs. 16%, P < 0.001). The AUC for PSS to predict a CRT response in Group B was 0.91 (P = 0.0001). CONCLUSIONS: Patients with a PSS >4 are the most likely to respond to CRT. Using this score system, a PSS score >4 can predict the probability of a CRT response up to 88% in patients with heart failure and a wide QRS duration.

Thoracic aortic atheroma severity predicts high-risk coronary anatomy in patients undergoing transesophageal echocardiography.

INTRODUCTION: We hypothesized a relationship between severity of thoracic aortic atheroma (AA) and prevalence of high-risk coronary anatomy (HRCA). MATERIAL AND METHODS: We investigated AA diagnosed by transesophageal echocardiography and HRCA diagnosed by coronary angiography in 187 patients. HRCA was defined as ≥ 50% stenosis of the left main coronary artery or significant 3-vessel coronary artery disease (≥ 70% narrowing). RESULTS: HRCA was present in 45 of 187 patients (24%). AA severity was grade I in 55 patients (29%), grade II in 71 patients (38%), grade III in 52 patients (28%), grade IV in 5 patients (3%), and grade V in 4 patients (2%). The area under receiver operating characteristic curve for AA grade predicting HRCA was 0.83 (p = 0.0001). The cut-off points of AA to predict HRCA was > II grade. The sensitivity and specificity of AA > grade II to predict HRCA were 76% and 81%, respectively. After adjustment for 10 variables with significant differences by univariate regression, AA > grade II was related to HRCA by multivariate regression (odds ratio = 7.5, p< 0.0001). During 41-month follow-up, 15 of 61 patients (25%) with AA >grade II and 10 of 126 patients (8%) with AA grade ≤ 2 died (p= 0.004). Survival by Kaplan-Meier plot in patients with AA > grade II was significantly decreased compared to patients with AA ≤ grade II (p= 0.002). CONCLUSIONS: AA > grade II is associated with a 7.5 times increase in HRCA and with a significant reduction in all-cause mortality.

A new baseline scoring system may help to predict response to cardiac resynchronization therapy.

INTRODUCTION: The PROSPECT trial reported no single echocardiographic measurement of dyssynchrony is recommended to improve patient selection for cardiac resynchronization therapy (CRT). MATERIAL AND METHODS: In 100 consecutive patients who received CRT, we analyzed 27 ECG and echocardiographic variables to predict a positive response to CRT defined as a left ventricular (LV) end systolic volume decrease of ≥ 15% after CRT. RESULTS: Right ventricular (RV) pacing-induced left bundle branch block (LBBB), time difference between LV ejection measured by tissue Doppler and pulsed wave Doppler (T(TDI-PW)), and wall motion score index (WMSI) were significantly associated with positive CRT response by multivariate regression. We assigned 1 point for RV pacing-induced LBBB, 1 point for WMSI ≤ 1.59, and 2 points for T(TDI-PW) > 50 ms. Overall mean response score was 1.79 ±1.39. Cutoff point for response score to predict positive response to CRT was > 2 by receiver operating characteristic (ROC) analysis. Area under ROC curve was 0.97 (p = 0.0001). Cardiac resynchronization therapy responders in patients with response score > 2 and ≤ 2 were 36/38 (95%) and 7/62 (11%, p < 0.001), respectively. After age and gender adjustment, the response score was related to CRT response (OR = 45.4, p < 0.0001). CONCLUSIONS: A response score generated from clinical, ECG and echocardiographic variables may be a useful predictor for CRT response. However, this needs to be validated.

Impact of left atrial volume in prediction of outcome after cardiac resynchronization therapy.

UNLABELLED: Left atrial volume index (LAVI) as a predictor of mortality has not been well investigated in patients with cardiac resynchronization therapy (CRT). The purpose of this study is to evaluate the impact of LAVI in predicting mortality in CRT patients. METHODS: We studied 100 consecutive patients who received CRT (male 73, age 69.9 ± 9.6 years). The follow-up duration of all echocardiographic measurements was 14.4 ± 10.5 months after CRT. LAVI was measured from apical views on two-dimensional echocardiography by bi-plane rule. A decrease of left ventricular end systolic volume ≥ 15% after CRT was defined as a positive response to CRT. RESULTS: The mean LAVI at baseline was 59.9 ± 22.7 ml/m(2). LAVI in patients who died (78.2 ± 27.5 ml/m(2)) was significantly greater than those who survived (55.9 ± 19.5 ml/m(2), p<0.0001) during follow-up of 17 ± 10.6 months. The area under ROC curve (AUC) for LAVI predicting death was 0.77 (p=0.0001). The cutoff point for LAVI predicting death was LAVI>59.4 ml/m(2). LAVI>59.4 ml/m(2) was related to mortality by Cox proportional univariate regression [hazard ratio (HR)=5.15, 95% CI=1.48-17.93, p=0.01]. After adjustment for the variables with significant difference by univariate regression, LAVI>59.4 ml/m(2) was continuously related to mortality by multivariate regression (HR=4.56, 95% CI, 1.30-15.97, p=0.02). LAVI>59.4 ml/m(2) was associated with a near 5-fold increase in mortality during follow-up of 17 ± 10.6 months. CONCLUSION: Patients who have LAVI>59.4 ml/m(2) continue to have increased mortality despite CRT.

Impact of statin use on heart failure mortality.

BACKGROUND: There is conflicting data regarding the mortality benefit of statins in patients with heart failure. The objectives of our study were to determine whether statin therapy is associated with decreased all-cause mortality and to assess the effect of incremental duration of therapy. METHODS: We studied 10,510 consecutive patients from the Veterans Affairs health system with a diagnosis of heart failure from January 2002 through December 2006. Mean follow-up was 2.66 years. Statin use and duration of therapy were identified. Veterans were classified into four groups based on duration of statin use during the study period (none, 1-25%, 26-75% and >75% use of statins). Logistic regression was performed to identify the association between incident statin use and all-cause mortality following a diagnosis of heart failure. The Kaplan-Meier method was employed to assess for differences in survival time between the four statin use classifications. RESULTS: Statin use was significantly associated with decreased all-cause mortality following a diagnosis of heart failure after controlling for age, gender, concurrent medications and comorbid diagnoses [χ(3)(2) (N = 10,510) = 1077.82, p < 0.001]. The benefit was seen within a relatively short duration (within 1 year) after starting statins, and in patients with <25% use of statins, there was no mortality benefit. CONCLUSION: Veterans who were not exposed to statin therapy at any time during the study period were 1.56 times more likely to suffer all-cause mortality.

Effectiveness of Thrombolytic Therapy in Acute Embolic Stroke due to Infective Endocarditis.

Objective. To identify the role of thrombolytic therapy in acute embolic stroke due to infective endocarditis. Design. Case report. Setting. University hospital. Patient. A 70-year-old male presented with acute onset aphasia and hemiparesis due to infective endocarditis. His head computerized tomographic scan revealed left parietal sulcal effacement. He was given intravenous tissue plasminogen activator with significant resolution of the neurologic deficits without complications. Main Outcome Measures. Physical examination, National Institute of Health Stroke Scale, radiologic examination results. Conclusions. Thrombolytic therapy in selected cases of stroke due to infective endocarditis manifesting as major neurologic deficits can be considered as an option after careful consideration of risks and benefits. The basis for such favorable response rests in the presence of fibrin as a major constituent of the vegetation. The risk of precipitating hemorrhage with thrombolytic therapy especially with large infarcts and mycotic aneurysms should be weighed against the benefits of averting a major neurologic deficit.

Effect of medical therapy on left ventricular ejection fraction in patients with systolic heart failure and narrow QRS duration with and without ischemic heart disease and left ventricular mechanical dyssynchrony.

We studied 99 consecutive patients with class III-IV systolic heart failure with a left ventricular ejection fraction (LVEF) < or =35% and a QRS duration <120 milliseconds. Patients with cardiac resynchronization therapy were excluded. Echocardiography was performed in all patients before and after optimal standard heart failure therapy. The septal-to-posterior wall motion delay (SPWMD) > or =130 milliseconds on echocardiogram was defined as left ventricular mechanical dyssynchrony (LVMD). Sixty-nine of 99 patients (70%) had ischemic heart disease. During follow-up of 15.2 +/- 9.8 months, LVEF improvement > or =15% was greater patients in nonischemic group (50%, 15/30) than in ischemic group (9%, 6/69; P < 0.001). After adjustment for age, gender, and clinical and echocardiographic characteristics, ischemic heart disease and grade of coronary disease were persistently related to LVEF improvement > or =15% (P = 0.03 and 0.02, respectively). Twenty of 99 patients (20%) had SPWMD > or =130 milliseconds (LVMD group), and 79 of 99 patients (80%) had SPWMD <130 milliseconds (non-LVMD group). LVEF increased in both groups (P = 0.005) during follow-up, but the percentage of patients with LVEF improvement > or =15% in LVMD was greater compared with patients without LVMD (40% versus 16%, respectively, P = 0.03). In conclusion, the improvement of LVEF in patients with systolic heart failure and narrow QRS was greater in patients with nonischemic heart disease and LVMD compared with patients with ischemic heart disease and absence of LVMD during medical therapy without cardiac resynchronization therapy.