Comparison of Medical Therapy, Valve Surgery, and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis.

BACKGROUND: The opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided infective endocarditis are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients at high risk for re-infection of a prosthetic valve but lacks robust outcomes data. This retrospective analysis compares the primary outcome of death within 1 year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy alone vs percutaneous mechanical aspiration or valve surgery. METHODS: The authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic-and outcomes-related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting. RESULTS: Between January 1, 2009, and December 31, 2018, 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the 3 treatment groups (P = .15). Vegetation size > 2.0 cm was associated with increased 1-year mortality (hazard ratio 3.01; P = .03). Addiction medicine consultation was associated with decreased 1-year mortality (hazard ratio 0.117; P = .0008). CONCLUSION: The study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated tricuspid valve infective endocarditis. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.

The Evolving Trends in Infective Endocarditis and Determinants of Mortality: a 10-year Experience From a Tertiary Care Epicenter.

The epidemiology of infective endocarditis (IE) continues to evolve in areas affected by the opioid epidemic. Understanding the demographics of the disease allows us to better tailor therapy towards this at-risk population. This was an observational study of adults (age ≥ 18) admitted to the University of Kentucky hospital with IE between January 2009 and December 2018. 1,255 patients were included in the final analysis. The mean age was 42 years, 45% were female and injection drug use was seen in 66% of patients. On multivariable analysis, higher Charlson comorbidity indices, left sided, and multivalve involvement were associated with increased mortality, whereas surgical intervention demonstrated a trend towards lower mortality. Our results highlight the alarming increase in injection drug use related IE and the high mortality rates despite therapeutic advances. Patients with left sided IE, multivalve involvement and a higher Charlson comorbidity index had decreased survival.

Avoidance of ST-Segment-Elevation Myocardial Infarction Treatment for >1 Week Due to COVID-19 Fears.

During the coronavirus disease 2019 (COVID-19) pandemic, social distancing guidelines have negatively affected the care-seeking behavior of patients with chronic medical conditions, including those with cardiovascular disease. We report the case of a 60-year-old man with vague gastrointestinal symptoms who waited more than 1 week to seek treatment for fear of COVID-19 infection. On presentation at another hospital, he was found to have had an anterior myocardial infarction, and he underwent percutaneous coronary intervention to stent an occluded proximal left anterior descending coronary artery. Subsequently, the patient experienced refractory cardiogenic shock and, during his transfer to our hospital, refractory ventricular tachycardia, which ultimately proved fatal.

Infective endocarditis in pregnancy from 2009 to 2019: the consequences of injection drug use.

BACKGROUND: Endocarditis during pregnancy carries a maternal mortality of up to 30%, but prior publications do not reflect the current opioid epidemic. CASE PRESENTATIONS: We reviewed our institution's infective endocarditis registry from 2009 to 2019 and identified 19 females with endocarditis during pregnancy in order to compare our contemporary outcomes with historical reports. In our cohort, intravenous drug use was reported in all cases, and the most common pathogen was Staphylococcus (74%) followed by Serratia (13%). The tricuspid valve was involved in 18 (95%) patients, and contrary to prior reports, all but two patients were managed conservatively with antibiotics alone. Maternal and infant mortality (5% and 0%, respectively) were lower in our cohort compared to all previous reviews. CONCLUSION: We conclude that the better outcomes seen in this report are likely due to the younger age of the patients and the more frequent right-sided valvular involvement. SUMMARY: This review highlights contemporary outcomes in endocarditis during pregnancy. We review historical case reports in light of the opioid epidemic. We observed more Staphylococcus, more right-sided valvular involvement, and more conservative management as well as improved maternal and foetal mortality.

Transradial Approach to Coronary Angiography and Percutaneous Intervention in Patients With Dextrocardia.

Patients with dextrocardia present unique challenges in the catheterization laboratory. Variable coronary artery anatomy impacts percutaneous access, catheter selection and manipulation, and image acquisition. This is a review of all published reports of radial artery access for diagnostic and/or therapeutic coronary interventions in patients with dextrocardia. We conclude that the radial approach is safe and effective in these patients and should be used without hesitation. In addition, interventionalists should consider use of multipurpose catheters and possess an understanding of how mirror-image fluoroscopy impacts catheter manipulation. Furthermore, we propose a stepwise approach to arterial access, fluoroscopy, and catheter selection for operator reference while treating dextrocardia patients.

Response to cardiac resynchronization therapy in non-ischemic cardiomyopathy is unrelated to medical therapy.

INTRODUCTION: Current guidelines recommend at least 3 months of guideline-directed medical therapy (GDMT) for patients with a new onset of non-ischemic cardiomyopathy (NICM) and left bundle branch block (LBBB) prior to cardiac resynchronization therapy (CRT). For patients who do not receive optimal GDMT, response to CRT is unknown. METHODS: Patients with NICM and LBBB with QRS ≥ 120 ms were identified among all patients who underwent CRT. Patients who received GDMT for ≥ 3 months before CRT were compared to those who did not. Among 38 patients who met inclusion criteria, 24 received optimal GDMT prior to implantation (Group 1) and 14 did not (Group 2). RESULTS: QRS narrowing occurred in Group 1 (160 ± 9 ms to 138 ± 20 ms, P = 0.001) and Group 2 (160 ± 17 ms to 139 ± 30 ms, P = 0.021). Left ventricular ejection fraction (LVEF) improvement occurred in Group 1 (21.3 ± 5.9% to 34.4 ± 13.9%, P < 0.001) and Group 2 (18.8 ± 4.7% to 31.1 ± 13%, P = 0.010). QRS interval and LVEF changes were similar between groups (P = NS). There was a trend towards greater CRT response in women than in men, although differences did not reach statistical significance. CONCLUSION: In patients with NICM and LBBB, CRT is associated with improvements in LV size and function independent of prior GDMT. The ability of resynchronization to improve LVEF without GDMT suggests that CRT without waiting 3 months for GDMT optimization may benefit some patients with NICM and LBBB.

Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function.

BACKGROUND: Echocardiographic atrioventricular (AV) optimization after cardiac resynchronization therapy (CRT) is uncommon due to time constraints and the use of vendor-specific device algorithms. It remains unclear whether optimization of mitral inflow velocities can still be useful. We aimed to investigate post implantation left ventricular (LV) inflow patterns to determine the incidence of AV dyssynchrony from empirically set devices. METHODS: This was a retrospective study of patients undergoing CRT using empiric device settings. Forty-eight patients with clinical, echocardiographic, and pacemaker follow-up were grouped by their post implantation LV filling pattern. Baseline characteristics and echocardiographic measurements were compared with post implantation findings at median 6.3 months (interquartile range [IQR], 3.9-17.0). RESULTS: Twenty-four patients demonstrated AV dyssynchrony (Group 1) after CRT, and 24 patients did not (Group 2). Group 1 patients had less LV reverse remodeling compared to Group 2 patients (ΔLV end-diastolic volume: -3.6 mL vs -49.5 mL, P<.05; ΔLV end-systolic volume: -16.9 mL vs -53.5 mL, P<.05) and did not experience significant improvements in LV outflow tract velocity time integral, stroke volume, or LV ejection fraction. There were no differences in new-onset atrial fibrillation, heart failure readmissions, or mortality between groups. CONCLUSION: Our study suggests that up to 50% of patients with empiric device settings have AV dyssynchrony at 6 months despite atrioventricular delay optimization (AVO) algorithms. As AV dyssynchrony is common and has proven to be modifiable, a strategic approach to Doppler echocardiography-guided AVO after CRT is warranted, particularly in nonresponders where the LV filling pattern is fused or truncated.