Recurrent infective endocarditis with uncommon Gram-negative Pasteurella multocida and Pseudomonas aeruginosa: a case report

Infective endocarditis (IE) due to Gram-negative bacteria is a rare occurrence, with a relative frequency of less than 10% compared to that caused by Gram-positive bacteria. Herein is presented the fatal case of a 66-year-old man who had undergone mechanical aortic valve replacement 10 years previously, and developed aortic valve IE after sepsis with Pasteurella multocida caused by a cat bite at the left medial ankle. In addition, the patient suffered five months later from mitral and aortic valve endocarditis caused by Pseudomonas aeruginosa. Recurrent surgical therapy was mandatory. This unique case of recurrent Gram-negative IE shows that the condition must still be regarded as complex and often fatal, despite adequate medical and surgical treatment.

First clinical experience and 1-year follow-up with the sutureless 3F-Enable aortic valve prosthesis

BACKGROUND

Aortic valve replacement (AVR) with extracorporeal circulation (ECC) is currently the treatment of choice for symptomatic aortic stenosis. However, patients with multiple high-risk comorbid conditions may benefit from reduced ECC time and thus, reduced myocardial ischemia, by the use of sutureless AVR. We describe the initial experience and 1-year results of our first 3F-Enable AVR implants.

METHODS

Between 09/05 and 12/05, six patients (age 74+/-1.8 years; three females) with symptomatic aortic stenosis (NYHA III) underwent AVR with an equine pericardial and nitinol-stented sutureless prosthesis. For additional safety up to three stay sutures were placed. Echocardiography was performed preoperatively, intraoperatively, at 6- and 12-month follow-up. Clinical data, adverse events and patient outcome were recorded prospectively.

RESULTS

Prosthesis sizes were 27 mm (n=3), 25 mm (n=1), 23 mm (n=1) and 21 mm (n=1). ECC time was 87+/-32 min; aortic clamp time was 56+/-24 min. Prosthesis deployment time was 148 +/- 173 s. There were no intraoperative deaths or complications. At 12-month follow-up mean pressure gradients (MPG) were 6.8+/-3.5 mmHg and aortic valve area (AVA) was 2.2 +/- 0.5 cm(2). One patient underwent successful redo AVR after 8 months due to severe paravalvular leakage (PVL), and one patient died due to lung cancer 10 months after surgery. At 12 months follow-up four out of six patients are alive and asymptotic (NYHA I) with the 3F-Enable aortic valve prosthesis, however, one patient showed mild paravalvular leakage.

CONCLUSIONS

These first 1-year follow-up data suggest the feasibility of this new concept of sutureless aortic valve implantation. However, severe aortic insufficiency at 8 months and paravalvular leakage at 1-year follow-up should prompt further procedural and device enhancements.

Prognostic impact of previous percutaneous coronary intervention in patients with diabetes mellitus and triple-vessel disease undergoing coronary artery bypass surgery

OBJECTIVES

In the current era of stent usage, percutaneous coronary intervention is more frequently performed as the initial revascularization strategy in multivessel disease before patients are finally referred to coronary artery bypass grafting. We sought to determine whether previous PCI has a prognostic impact on outcome in patients with diabetes mellitus and triple-vessel disease.

METHODS

Between January 2000 and March 2006, 621 consecutive patients with diabetes mellitus and triple-vessel disease undergoing isolated first-time coronary artery bypass grafting as the primary revascularization procedure (group 1) were evaluated for in-hospital mortality and major adverse cardiac events and compared with 128 patients with diabetes mellitus and triple-vessel disease treated during the same time period with previous percutaneous coronary intervention before coronary artery bypass grafting (group 2).

RESULTS

All-cause in-hospital mortality was 2.9% in group 1 and 7.8% in group 2 (odds ratio, 2.84; 95% confidence interval, 1.19-6.68; P = .02). In-hospital major adverse cardiac events were identified in 6.1% and 14.1% (odds ratio, 2.51; 95% confidence interval, 1.32-4.73; P < .005), respectively. Risk-adjusted multivariate logistic regression analysis of previous percutaneous coronary intervention significantly correlated with in-hospital mortality (odds ratio, 2.87; 95% confidence interval, 1.29-6.37; P = .03) and major adverse cardiac events (odds ratio, 2.54; 95% confidence interval, 1.39-4.62; P = .01). After computed propensity score matching based on 12 major preoperative risk factors to control selection bias, conditional regression analysis confirmed previous percutaneous coronary intervention to be associated with all-cause in-hospital mortality (odds ratio, 2.97; 95% confidence interval, 1.12-7.86; P = .03) and major adverse cardiac events (odds ratio, 2.46; 95% confidence interval, 1.18-5.15; P = .02) in these patients.

CONCLUSION

Previous percutaneous coronary intervention before coronary artery bypass grafting in patients with diabetes mellitus and triple-vessel disease independently increases the risk for in-hospital mortality and major adverse cardiac events.

Predictors and Outcomes of Coronary Artery Bypass Grafting in ST Elevation Myocardial Infarction

BACKGROUND

Treatment of ST-elevation myocardial infarction has undergone great evolution since introduction of percutaneous coronary intervention (PCI). The purpose was therefore to assess the outcome of patients with ST-elevation myocardial infarction undergoing surgical revascularization with coronary artery bypass grafting (CABG).

METHODS

A total of 138 consecutive patients with ST-elevation myocardial infarction underwent CABG therapy between January 2000 and January 2007 at our institution. Prospectively recorded preoperative, intraoperative, and postoperative data were retrospectively screened for in-hospital mortality and major adverse cardiac events (MACE).

RESULTS

The delay between the onset of ST-elevation myocardial infarction symptoms and CABG procedures was within 6 hours in 37 patients, 7 to 24 hours in 21, 1 to 3 days in 15, 4 to 7 days in 24, and 8 to 14 days in 41 patients. Cardiogenic shock (Killip class > or = III) was present in 38 patients (28%), and 37 patients (27%) were referred for CABG after failed PCI. Overall in-hospital mortality was 8.7%, but mortality varied between 10.8% (< or = 6 hours), 23.8% (7 to 24 hours), 6.7% (1 to 3 days), 4.2% (4 to 7 days), and 2.4% (8 to 14 days), depending on time interval from symptom onset to operation. Overall, more nonsurvivors were women (58% versus 23%; p < 0.01), had higher preoperative cardiac troponin I levels (13.2 +/- 9.8 versus 4.5 +/- 4.2 ng/ml; p < 0.0001), and were more frequently in cardiogenic shock (83% versus 22%; p < 0.0001). Unadjusted univariable and risk-adjusted multivariable logistic regression analysis revealed age, female sex, preoperative cardiac troponin I levels, and cardiogenic shock to be the most potent predictors of in-hospital death and MACE.

CONCLUSIONS

CABG in ST-elevation myocardial infarction can be performed with acceptable risk by incorporating adequate management strategies. However, female sex, preoperative cardiac troponin I level, preoperative cardiogenic shock, and time to operation are major variables of mortality and morbidity results.

PDE-5 inhibitor donor intravenous preconditioning is superior to supplementation in standard preservation solution in experimental lung transplantation☆

OBJECTIVE

Improvement of preservation is still a major research objective in lung transplantation. The effects of phosphodiesterase-5 (PDE-5) inhibitors during procurement are still not clear. It was the aim of this study to investigate the effect of sildenafil on post-transplanted lung function in a porcine model using different application procedures.

METHODS

In control group lungs were flushed with buffered low-potassium dextran (LPD) solution (I) and compared to LPD solution with supplementation of 0.15 mg/kg body weight (BW) sildenafil (II), whereas in a third group 0.15 mg/kg BW sildenafil was administered intravenously 20 min prior to LPD flushing (III). All grafts were stored for 24 h at 4-6 degrees C. Hemodynamics and blood gases were monitored until 6 h after reperfusion. Lung tissue was taken for wet/dry ratio assessment.

RESULTS

All animals of groups I and III survived the entire observation period in contrast to four animals of group II which died within 4 h after reperfusion due to severe reperfusion injury. Group II showed a lower mean PAP and a reduced pulmonary vascular resistance (PVR) throughout the observation period, but did not reach significance due to low number of surviving animals. Group III achieved significantly improved PO2/FiO2 fraction at all timepoints and a significant reduced PVR [434+/-98 vs 594+/-184 dyn s cm(-5), II vs I; mean+/-SD, p<0.01] at 6 h. Wet/dry ratio was significantly higher in group II throughout the experiment.

CONCLUSIONS

Sildenafil allows for a better graft function after 24 h ischemia when given prior to standard flushing and preservation. This effect can be explained by a complete/homogenous preservation achieved by selective pulmonal vasodilatation. However, this effect seems to persist when sildenafil remains in the storage solution, leading to severe pulmonary edema.

Minimally invasive endoscopic port-access intracardiac surgery with one lung ventilation: impact on gas exchange and anaesthesia resources

Minimally invasive endoscopic intracardiac surgery including one lung ventilation has been proposed to decrease surgical trauma but its impact on oxygenation and resource consumption has not been reported. We compared effects on gas exchange, induction, total anaesthesia time, staffing costs, and complications in 42 consecutive patients to a matched group undergoing similar surgery conventionally. Use of endoscopic compared to conventional surgery evoked a decrease in the P(a)o(2)/F(I)o(2) ratio (mean (SD) 24.1 (14.9) vs 48.9 (14) kPa, p < 0.05) following termination of bypass with one lung ventilation (10 patients showed a P(a)o(2)/F(i)o(2) below 13.3 kPa (100 mmHg)). There was also an increase of anaesthesia induction time (47 (13) vs 31 (9) min, p < 0.05), and an increase by 156 min of total anaesthesia time (474 (89) vs 321 (69) min, p < 0.05). Anaesthetist staffing costs increased by 300%. Thus, minimally invasive endoscopic intracardiac surgery consumes many more anaesthesia resources than conventional surgery and can result in hypoxaemia, but overall can be considered feasible provided that extensive continuous monitoring is employed.

VEGF is important for early liver regeneration after partial hepatectomy

BACKGROUND

The aim of the study was to determine the role of Vascular Endothelial Growth Factor (VEGF) on the microvasculature and on angiogenetic gene expression after partial hepatectomy (PH) in the rat model.

METHODS

To determine the effect of exogenous and endogenous VEGF after PH, rats were subjected to 70% PH and treated either with VEGF, anti-VEGF or NaCl. Postoperatively (3-168 h), vessel density (VD), vessel diameter (VDi), and intersinusoidal space, liver body weight ratio (LBR), hepatic proliferation and biochemical markers were assessed. To further elucidate the underlying molecular mechanisms hepatic gene expression was determined by customized cDNA arrays and quantitative RT-PCR.

RESULTS

In the VEGF group, VD, VDi, and LBR were significantly increased compared with anti-VEGF or controls. Blockage of endogenous VEGF led to a marked increase of biochemical markers. Anti-VEGF almost completely suppressed and VEGF markedly enhanced hepatic proliferation in the first 24 h after surgery. This was associated with a modulation of cell cycle control genes (PC4, Gadd45a, Tis21/BTG2), v-jun, and CD14 by VEGF.

CONCLUSIONS

VEGF plays an important role in liver regeneration and this may be due in part through its effects on neovascularization. Whether it may, when given therapeutically, represent a strategy to optimize liver regeneration in problematic patients needs to be clarified.