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Mishra AK, Bansal K, Al-Seykal I, Bhattad PB, George AA, Jha A, Sharma N, Sargent J, Kranis MJ. Echocardiographic predictors and associated outcomes of multiple vegetations in infective endocarditis: A pilot study. World J Cardiol 2024; 16:318-328. [DOI: 10.4330/wjc.v16.i6.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/27/2024] [Accepted: 05/15/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Infective endocarditis (IE) is a life-threatening infection with an annual mortality of 40%. Embolic events reported in up to 80% of patients. Vegetations of > 10 mm size are associated with increased embolic events and poor prognosis. There is a paucity of literature on the association of multiple vegetations with outcome.
AIM To study the echocardiographic (ECHO) features and outcomes associated with the presence of multiple vegetations.
METHODS In this retrospective, single-center, cohort study patients diagnosed with IE were recruited from June 2017 to June 2019. A total of 84 patients were diagnosed to have IE, of whom 67 with vegetation were identified. Baseline demographic, clinical, laboratory, and ECHO parameters were reviewed. Outcomes that were studied included recurrent admission, embolic phenomenon, and mortality.
RESULTS Twenty-three (34%) patients were noted to have multiple vegetations, 13 (56.5%) were male and 10 (43.5%) were female. The mean age of these patients was 50. Eight (35%) had a prior episode of IE. ECHO features of moderate to severe valvular regurgitation [odds ratio (OR) = 4], presence of pacemaker lead (OR = 4.8), impaired left ventricle (LV) relaxation (OR = 4), and elevated pulmonary artery systolic pressure (PASP) (OR = 2.2) are associated with higher odds of multiple vegetations. Of these moderate to severe valvular regurgitation (P = 0.028), pacemaker lead (P = 0.039) and impaired relaxation (P = 0.028) were statistically significant. These patients were noted to have an increased association of recurrent admissions (OR = 3.6), recurrent bacteremia (OR = 2.4), embolic phenomenon (OR = 2.5), intensive care unit stay (OR = 2.8), hypotension (OR = 2.1), surgical intervention (OR = 2.8) and device removal (OR = 4.8). Of this device removal (P = 0.039) and recurrent admissions (P = 0.017) were statistically significant.
CONCLUSION This study highlights the associations of ECHO predictors and outcomes in patients with IE having multiple vegetations. ECHO features of moderate to severe regurgitation, presence of pacemaker lead, impaired LV relaxation, and elevated PASP and outcomes including recurrent admissions and device removal were found to be associated with multiple vegetations.
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Affiliation(s)
- Ajay Kumar Mishra
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Kannu Bansal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Ibragim Al-Seykal
- Department of Medicine, Division of Cardiology, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Pradnya B Bhattad
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Anu Anna George
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Anil Jha
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Nitish Sharma
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Jennifer Sargent
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Mark J Kranis
- Division of Cardiovascular Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
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Petersen JK, Østergaard L, Fosbøl EL. Role of echocardiography in the diagnosis and clinical management of infective endocarditis. Indian J Thorac Cardiovasc Surg 2024; 40:16-28. [PMID: 38827556 PMCID: PMC11139831 DOI: 10.1007/s12055-023-01668-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 06/04/2024] Open
Abstract
Infective endocarditis (IE) is a deadly disease, constituting both diagnostic and treatment challenges. A positive outcome requires rapid and accurate diagnosis, and for that, echocardiography unequivocally remains the cornerstone. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have complementary roles and have been markedly improved during the last decades. The transthoracic modality is the recommended first-line approach but may only be sufficient in patients where the probability of IE is low and/or with clear acoustic windows, especially in patients with right-sided IE. The transesophageal modality is superior to TTE in most aspects and is recommended for all other patients. Both TTE and TEE may delineate vegetation location and size, assess for paravalvular extension of infection, and have the added advantage of defining the hemodynamic effects of valvular or device infection. However, echocardiography still has significant limitations, and novel imaging techniques are increasingly being exploited to improve diagnostic potential. Cardiac computed tomography (CT) performs better than TEE in the detection of abscess or pseudoaneurysm, while magnetic resonance imaging (MRI) has limited value in the diagnostic phase of IE but adds knowledge to the evaluation of extracardiac events. Nuclear molecular techniques are evolving as key supplementary methods in difficult-to-diagnose cases. Although newer imaging modalities are undergoing preliminary evaluation and multimodal imaging will play an increasing role in IE, echocardiography will continue to be pivotal in patients with IE for the foreseeable future.
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Affiliation(s)
- Jeppe Kofoed Petersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Lauge Østergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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Dayer MJ, Quintero-Martinez JA, Thornhill MH, Chambers JB, Pettersson GB, Baddour LM. Recent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4. J Am Coll Cardiol 2024; 83:1431-1443. [PMID: 38599719 DOI: 10.1016/j.jacc.2023.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/27/2023] [Accepted: 12/05/2023] [Indexed: 04/12/2024]
Abstract
This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios.
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Affiliation(s)
- Mark J Dayer
- Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland; Faculty of Health, University of Plymouth, Plymouth, United Kingdom.
| | - Juan A Quintero-Martinez
- Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Martin H Thornhill
- Department of Oral and Maxillofacial Medicine, Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom
| | - John B Chambers
- Emeritus Professor of Clinical Cardiology at Guy's and St Thomas' NHS Trust, London, United Kingdom, and Kings College, London, United Kingdom
| | | | - Larry M Baddour
- Department of Medicine and Department of Cardiovascular Medicine, Division of Public Health, Infectious Diseases and Occupational Health, Mayo Clinic, Rochester, Minnesota, USA
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Padilla Bermejo A, Pena Pardo FJ, Noriega-Álvarez E, Amo-Salas M, Sicilia Pozo MDLN, García Vicente AM, Poblete-García VM. Dual-Time-Point 18F-FDG PET/CT in Infective Endocarditis: Impact of Delayed Imaging in the Definitive Diagnosis of Endocarditis. Biomedicines 2024; 12:861. [PMID: 38672215 PMCID: PMC11048229 DOI: 10.3390/biomedicines12040861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/02/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Infective endocarditis (IE) is a major public health condition due to the associated high morbidity and mortality. Our objective was to evaluate the utility of dual-time 2-deoxy-2-[18F] fluoro-D-glucose (18F-FDG) Positron Emission Tomography/Computed Tomography (PET/CT) imaging in the diagnosis of active IE in patients with suspected native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). For this purpose, a retrospective study was carried out, including patients suspicious of NVE or PVE who underwent a dual-time-point 18F-FDG PET/CT. A final diagnosis was established by the Endocarditis Team after patient follow-up using all the available findings. Sixty-nine patients were assessed. A final diagnosis of NVE was established in 3 patients of the 34 by 18F-FDG PET/CT and in the case of PVE was established in 20 patients of the 35. A statistically significant association was found when evaluating the association between PET diagnosis at early acquisition and final diagnosis of IE (χ2 = 30.198, p < 0.001) and PET diagnosis at delayed acquisition for final diagnosis of IE (χ2 = 9.412, p = 0.002). Delayed PET/CT imaging determined the IE diagnosis in 16/58 of the studies. In conclusion, delayed 18F-FDG PET/CT imaging seems to be useful in improving the definitive diagnosis of IE.
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Affiliation(s)
- Amanda Padilla Bermejo
- Nuclear Medicine Department, Ciudad Real General University Hospital, 13005 Ciudad Real, Spain; (A.P.B.); (F.J.P.P.); (M.d.l.N.S.P.); (V.M.P.-G.)
| | - Francisco José Pena Pardo
- Nuclear Medicine Department, Ciudad Real General University Hospital, 13005 Ciudad Real, Spain; (A.P.B.); (F.J.P.P.); (M.d.l.N.S.P.); (V.M.P.-G.)
| | - Edel Noriega-Álvarez
- Nuclear Medicine Department, Guadalajara University Hospital, 19002 Guadalajara, Spain
| | - Mariano Amo-Salas
- Mathematics Department, Castilla La Mancha University, 13071 Ciudad Real, Spain;
| | - María de las Nieves Sicilia Pozo
- Nuclear Medicine Department, Ciudad Real General University Hospital, 13005 Ciudad Real, Spain; (A.P.B.); (F.J.P.P.); (M.d.l.N.S.P.); (V.M.P.-G.)
| | | | - Víctor Manuel Poblete-García
- Nuclear Medicine Department, Ciudad Real General University Hospital, 13005 Ciudad Real, Spain; (A.P.B.); (F.J.P.P.); (M.d.l.N.S.P.); (V.M.P.-G.)
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Moore RA, Witten JC, Lowry AM, Shrestha NK, Blackstone EH, Unai S, Pettersson GB, Wierup P. Isolated mitral valve endocarditis: Patient, disease, and surgical factors that influence outcomes. J Thorac Cardiovasc Surg 2024; 167:127-140.e15. [PMID: 35927083 PMCID: PMC9532471 DOI: 10.1016/j.jtcvs.2022.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/21/2021] [Accepted: 01/23/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objectives of this study were to investigate patient characteristics, valve pathology, bacteriology, and surgical techniques related to outcome of patients who underwent surgery for isolated native (NVE) or prosthetic (PVE) mitral valve endocarditis. METHODS From January 2002 to January 2020, 447 isolated mitral endocarditis operations were performed, 326 for NVE and 121 for PVE. Multivariable analysis of time-related outcomes used random forest machine learning. RESULTS Staphylococcus aureus was the most common causative organism. Of 326 patients with NVE, 88 (27%) underwent standard mitral valve repair, 43 (13%) extended repair, and 195 (60%) valve replacement. Compared with NVE with standard repair, patients who underwent all other operations were older, had more comorbidities, worse cardiac function, and more invasive disease. Hospital mortality was 3.8% (n = 17); 0 (0%) after standard valve repair, 3 (7.0%) after extended repair, 8 (4.1%) after NVE replacement, and 6 (5.0%) after PVE re-replacement. Survival at 1, 5, and 10 years was 91%, 75%, and 62% after any repair and 86%, 62%, and 44% after replacement, respectively. The most important risk factor for mortality was renal failure. Risk-adjusted outcomes, including survival, were similar in all groups. Unadjusted extended repair outcomes, particularly early, were similar or worse than replacement in terms of reinfection, reintervention, regurgitation, gradient, and survival. CONCLUSIONS A patient- and pathology-tailored approach to surgery for isolated mitral valve endocarditis has low mortality and excellent results. Apparent superiority of standard valve repair is related to patient characteristics and pathology. Renal failure is the most powerful risk factor. In case of extensive destruction, extended repair shows no benefit over replacement.
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Affiliation(s)
- Ryan A Moore
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James C Witten
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nabin K Shrestha
- Department of Infectious Disease, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Per Wierup
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Khayata M, Sanchez Nadales A, Xu B. Contemporary applications of multimodality imaging in infective endocarditis. Expert Rev Cardiovasc Ther 2024; 22:27-39. [PMID: 37996246 DOI: 10.1080/14779072.2023.2288152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Infective endocarditis (IE) is an increasingly important condition with significant morbidity and mortality. With advancements in cardiovascular interventions including prosthetic valve implantation and utilization of intracardiac devices, the prevalence of IE is rising in the modern era. Early detection and management of this condition are critical. AREAS COVERED This review presents a contemporary review of the applications of multi-modality imaging in IE, taking a comparative approach of the various imaging modalities. EXPERT OPINION Transthoracic and transesophageal echocardiography are essential imaging modalities in establishing the diagnosis of IE, as well as evaluating for complications of IE. Other imaging modalities such as cardiac computed tomography and nuclear imaging play an important role as adjuvant imaging modalities for the evaluation of IE, particularly in prosthetic valve IE and cardiovascular implantable device associated IE. It is crucial to understand the strengths, weaknesses, and clinical application of each imaging modality, to improve the diagnosis, management, and outcomes of patients with IE.
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Affiliation(s)
- Mohamed Khayata
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydnell and Arnold Family Heart, Vascular, and Thoracic Institute, Cleveland, OH, USA
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Babes EE, Bustea C, Ilias TI, Babes VV, Luca SA, Luca CT, Radu AF, Tarce AG, Bungau AF, Bustea C. Multimodality Imaging Diagnosis in Infective Endocarditis. Life (Basel) 2023; 14:54. [PMID: 38255669 PMCID: PMC10821102 DOI: 10.3390/life14010054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/20/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Imaging is an important tool in the diagnosis and management of infective endocarditis (IE). Echocardiography is an essential examination, especially in native valve endocarditis (NVE), but its diagnostic accuracy is reduced in prosthetic valve endocarditis (PVE). The diagnostic ability is superior for transoesophageal echocardiography (TEE), but a negative test cannot exclude PVE. Both transthoracic echocardiography (TTE) and TEE can provide normal or inconclusive findings in up to 30% of cases, especially in patients with prosthetic devices. New advanced non-invasive imaging tests are increasingly used in the diagnosis of IE. Nuclear medicine imaging techniques have demonstrated their superiority over TEE for the diagnosis of PVE and cardiac implantable electronic device infective endocarditis (CIED-IE). Cardiac computed tomography angiography imaging is useful in PVE cases with inconclusive TTE and TEE investigations and for the evaluation of paravalvular complications. In the present review, imaging tools are described with their values and limitations for improving diagnosis in NVE, PVE and CIED-IE. Current knowledge about multimodality imaging approaches in IE and imaging methods to assess the local and distant complications of IE is also reviewed. Furthermore, a potential diagnostic work-up for different clinical scenarios is described. However, further studies are essential for refining diagnostic and management approaches in infective endocarditis, addressing limitations and optimizing advanced imaging techniques across different clinical scenarios.
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Affiliation(s)
- Elena Emilia Babes
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (E.E.B.); (A.-F.R.); (A.F.B.)
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (T.I.I.); (V.V.B.)
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Tiberia Ioana Ilias
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (T.I.I.); (V.V.B.)
| | - Victor Vlad Babes
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (T.I.I.); (V.V.B.)
| | - Silvia-Ana Luca
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Institute of Cardiovascular Diseases Timisoara, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 300310 Timisoara, Romania
| | - Constantin Tudor Luca
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Institute of Cardiovascular Diseases Timisoara, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 300310 Timisoara, Romania
| | - Andrei-Flavius Radu
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (E.E.B.); (A.-F.R.); (A.F.B.)
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Alexandra Georgiana Tarce
- Medicine Program of Study, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
| | - Alexa Florina Bungau
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (E.E.B.); (A.-F.R.); (A.F.B.)
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Cristian Bustea
- Department of Surgery, Oradea County Emergency Clinical Hospital, 410169 Oradea, Romania;
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Petkovic A, Menkovic N, Petrovic O, Bilbija I, Radovanovic NN, Stanisavljevic D, Putnik S, Maksimovic R, Ivanovic B. The Role of Echocardiography and Cardiac Computed Tomography in Diagnosis of Infective Endocarditis. J Clin Med 2023; 12:5482. [PMID: 37685577 PMCID: PMC10488865 DOI: 10.3390/jcm12175482] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/06/2023] [Accepted: 08/11/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Infective endocarditis (IE) is a rare disease with a high mortality rate and rising incidence, requiring timely and precise diagnosis in order to choose appropriate therapy. Imaging of morphologic lesions is an integrative part of diagnosis. Artifacts and the patient's habitus make echocardiography difficult to visualize advanced-form IE. Cardiac computed tomography (CCT) constantly shows an additive diagnostic value due to high resolution of cardiac anatomy. Conjecturally, joint application of both diagnostic tests improves overall sensitivity and specificity in diagnosing IE. METHODS Patients with definite IE underwent transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and CCT. We analyzed valvular and paravalvular IE lesions in all three imaging methods and compared them to surgical or autopsy findings. We calculated sensitivity, specificity, diagnostic accuracy, and positive and negative predictive value of both imaging tests individually and jointly used. RESULTS We examined 78 patients, male to female ratio 2:1, mean age 52.29 ± 16.62. We analyzed 85 valves, 70 native valves, 13 prosthetic valves, and 2 corrected valves due to Ozaki procedure, along with a central shunt and 4 pacemaker leads. As a single test, the sensitivity and specificity of CCT, TTE, and TEE for valvular lesions were 91.6/20%, 65.5/57.9%, and 60/84%, and paravalvular lesions were 100/0%, 46/10.5%, and 14.7/100%. When combined together, sensitivity and specificity for valvular lesions rose to 96.6/0% and paravalvular lesions to 100/0%. We also analyzed the diagnostic performance for each test in single and mutual application, per specific IE lesion. CONCLUSION In the individual application, CCT in comparison to TTE and TEE shows better diagnostic performance in detection of valvular and paravalvular lesions. In joint application, there is a statistically significant difference in performance compared to their single use, especially in prosthetic valves and invasive forms of IE native valves.
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Affiliation(s)
- Ana Petkovic
- Diagnostic Department of Center of Stereotaxic Radiosurgery, Clinic of Neurosurgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.P.); (N.M.)
| | - Nemanja Menkovic
- Diagnostic Department of Center of Stereotaxic Radiosurgery, Clinic of Neurosurgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.P.); (N.M.)
| | - Olga Petrovic
- Cardiology Clinic, University Clinical Center of Serbia, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Ilija Bilbija
- Department for Cardiac Surgery, University Clinical Center of Serbia, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.B.); (S.P.)
| | - Nikola N. Radovanovic
- Pacemaker Center, University Clinical Center of Serbia, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Dejana Stanisavljevic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Svetozar Putnik
- Department for Cardiac Surgery, University Clinical Center of Serbia, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.B.); (S.P.)
| | - Ruzica Maksimovic
- Center of Radiology, University Clinical Center of Serbia, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Branislava Ivanovic
- Cardiology Clinic, University Clinical Center of Serbia, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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Miao Y, Zhang Y, Yue L, Guan S, Feng W. Case report: Novel three-dimensional echocardiographic methods mapping aortic root pseudoaneurysm secondary to blood culture-negative endocarditis with bicuspid aortic valve involvement. Front Cardiovasc Med 2023; 10:1138390. [PMID: 37008335 PMCID: PMC10060794 DOI: 10.3389/fcvm.2023.1138390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/22/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundInfective endocarditis (IE), though uncommon, is a potentially lethal disease. Blood culture-negative endocarditis (BCNIE) accounts for 2.5%–31% of all cases of IE and can lead to life-threatening complications, including aortic root pseudoaneurysm. It is associated with considerable diagnostic and therapeutic dilemmas. TrueVue and TrueVue Glass include the latest two technologies applied in advanced three-dimensional echocardiography, which allow for novel photorealistic images of cardiac structures, and provide abundant previously unavailable diagnostic information. Herein, based on a series of novel three-dimensional echocardiographic methods, we report a case of BCNIE with aortic valve involvement, leading to aortic valve perforation and prolapse, and developing into a giant aortic root pseudoaneurysm.Case summaryIn this study, we presented a case of a 64-year-old man exhibiting symptoms of intermittent fever, asthenia, and dyspnea following light exertion. Physical examination, laboratory tests, and electrocardiograms were suspected of IE, though the results of blood cultures were exactly negative. Three-dimensional transthoracic echocardiography, as well as a series of novel advanced techniques, was adopted to clearly visualize the lesions of the aortic valve and aortic root. However, despite active medical treatment modalities, the patient eventually suffered from a sudden, unexpected death 5 days later.ConclusionBCNIE with aortic valve involvement and development into a giant aortic root pseudoaneurysm is a rare and serious clinical event. In addition, TrueVue and TrueVue Glass offer unprecedented photographic stereoscopic images, enhancing the diagnostic performance of such structural heart diseases.
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Al-Kebsi M, Al-Motarreb A, Al-Kadasi H, Al-Muqayad MH, Mangieri E, Capotosto L, Miraldi F, Mastroianni C, Vitarelli A. Peculiar clinical and diagnostic features of infective endocarditis in Yemen: Comparative analysis with a Western University Hospital. J Investig Med 2023; 71:132-139. [PMID: 36647330 DOI: 10.1177/10815589221143327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The aim of this study was to describe the pattern, characteristics, and outcomes of infective endocarditis (IE) in Yemen and compare the results with the findings of a Western university hospital. Patients (pts) with a final diagnosis of IE observed in Al-Thawra Sanaa Cardiac Center were prospectively enrolled in 1-year time period. Clinical and diagnostic findings were compared to clinical and diagnostic data of 50 pts with IE observed at Sapienza University Hospital in Rome, Italy. The mean age was 38 ± 6. Predisposing factors for IE were rheumatic heart disease (RHD) in 34 pts (68%), congenital heart disease in 9 pts (18%), prosthetic valve IE in 4 pts (8%), and previous IE in 3 pts (6%). Transthoracic echocardiography (TTE) was done in 50 pts and transesophageal echocardiography (TEE) in 25. Blood cultures were taken in all pts and were positive in 3 pts (6%) and negative in 47 (94%). TTE was positive in 34/50 pts (68%) and TEE in 20/25 (80%). Compared to Sapienza University pts, Al-Thawra Cardiac Center pts had a younger age (p = 0.003), more predisposing RHD (p = 0.0004), less prosthetic heart valves IE (p = 0.002), and more negative blood cultures (p = 0.0001). IE is still a common disease in Yemen among RHD pts and affects the younger age group. It has severe complications which need early diagnosis and proper management. Echocardiography is of prime diagnostic value in the absence of positive blood cultures. An effort should be made to prevent rheumatic fever and RHD.
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Affiliation(s)
- Mohammed Al-Kebsi
- Faculty of Medicine & Health Sciences, Sanaa University, Sanaa, Yemen
| | - Ahmed Al-Motarreb
- Faculty of Medicine & Health Sciences, Sanaa University, Sanaa, Yemen
| | | | | | - Enrico Mangieri
- Departments of Cardiology and Infectious Diseases, Sapienza University, Rome, Italy
| | - Lidia Capotosto
- Departments of Cardiology and Infectious Diseases, Sapienza University, Rome, Italy
| | - Fabio Miraldi
- Departments of Cardiology and Infectious Diseases, Sapienza University, Rome, Italy
| | - Claudio Mastroianni
- Departments of Cardiology and Infectious Diseases, Sapienza University, Rome, Italy
| | - Antonio Vitarelli
- Departments of Cardiology and Infectious Diseases, Sapienza University, Rome, Italy
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11
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Newell CF, Bridwell RE, Inman BL, Long B. Tattoo associated native valve infective endocarditis: A case report. Am J Emerg Med 2022; 60:227.e5-227.e7. [PMID: 35902328 DOI: 10.1016/j.ajem.2022.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022] Open
Abstract
Infective Endocarditis (IE) is an uncommon illness in the emergency department (ED) with significant associated morbidity. Patients with IE typically possess risk factors predisposing them to bacterial invasion. These risk factors include intravenous drug use, valvulopathies, valve replacement, poor oral hygiene, immunocompromised state, and recent invasive procedures. A rarer condition is tattoo-associated IE. Diagnosis of IE includes multiple blood cultures and echocardiography. Therapeutic interventions include prolonged intravenous antibiotics and potential surgery. Complications from IE can be severe, including organ injury from septic emboli, heart failure, valvular insufficiency, bacteremia, and fulminant septic shock. Prompt identification and treatment are necessary to reduce patient morbidity and mortality.
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Affiliation(s)
- Cody F Newell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, WA 98341, United States
| | - Brannon L Inman
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
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12
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The Interventricular Septum: Structure, Function, Dysfunction, and Diseases. J Clin Med 2022; 11:jcm11113227. [PMID: 35683618 PMCID: PMC9181036 DOI: 10.3390/jcm11113227] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/25/2022] [Accepted: 06/04/2022] [Indexed: 02/05/2023] Open
Abstract
Vertebrates developed pulmonary circulation and septated the heart into venous and arterial compartments, as the adaptation from aquatic to terrestrial life requires more oxygen and energy. The interventricular septum (IVS) accommodates the ventricular portion of the conduction system and contributes to the mechanical function of both ventricles. Conditions or diseases that affect IVS structure and function (e.g., hypertrophy, defects, other) may lead to ventricular pump failure and/or ventricular arrhythmias with grave consequences. IVS structure and function can be evaluated today using current imaging techniques. Effective therapies can be provided in most cases, although definitions of underlying etiologies may not always be easy, particularly in the elderly due to overlap between genetic and acquired causes of IVS hypertrophy, the most common being IVS abnormality. In this review, state-of-the-art information regarding IVS morphology, physiology, physiopathology, and disease is presented.
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13
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Daubenspeck DK, Hackett IS, Patel AR, Chaney MA. Diagnosing Endocarditis: Get the Picture?! J Cardiothorac Vasc Anesth 2022; 36:2248-2252. [PMID: 35292187 DOI: 10.1053/j.jvca.2022.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Ian S Hackett
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL
| | - Amit R Patel
- Cardiac MRI and CT, Department of Medicine and Radiology, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
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14
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Abstract
The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.
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15
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Marcos-Garces V, Gabaldon-Perez A, Merenciano-Gonzalez H, Soler M, Lorenzo-Hernandez M, Nuñez-Marin G, de la Espriella R, Bonanad C, Nuñez J, Chorro FJ, Bodi V, Santas E. Applicability of Echocardiographic Strict Negative Criteria for Suspected Infective Endocarditis. Am J Cardiol 2022; 162:156-162. [PMID: 34728063 DOI: 10.1016/j.amjcard.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/02/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022]
Abstract
Echocardiography is the cornerstone imaging technique in the diagnosis of infective endocarditis (IE) but is often misused in clinical practice. Recently, strict negative criteria have been proposed to avoid unnecessary follow-up echocardiograms. We aimed to evaluate the use of echocardiography in real-world clinical daily practice and the usefulness of these criteria in the diagnosis of IE. We retrospectively retrieved every echocardiogram performed in our center for suspected IE between 2014 and 2018, including 905 transthoracic echocardiograms (TTEs). Of these, 451 (49.8%) fulfilled the strict negative criteria (group 1). In this group, IE was seldom diagnosed (n = 4, 0.9%). In 338 patients (37.4%) no signs of IE were evident, but they did not fulfill the strict negative criteria (group 2). A follow-up echocardiogram and definitive diagnosis of IE were more frequent (n = 48, 14.2% and n = 20, 5.9%). Finally, in 116 patients (12.8%) the initial TTE showed typical or suggestive signs of IE, in whom the diagnosis was confirmed in 48 patients (41.4%). A definitive diagnosis of IE was established in a minority of the study population (n = 72, 8%). Only 1 readmission for underdiagnosis of IE was noted on group 2. We conclude that in a real-life setting only a minority of patients in whom IE was suspected had a definitive diagnosis. An initial TTE for suspected IE fulfilling the strict negative criteria predicts both a low probability of requesting a follow-up study and of a definitive diagnosis of IE.
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Affiliation(s)
- Victor Marcos-Garces
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain
| | - Ana Gabaldon-Perez
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | | | - Meritxell Soler
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | | | - Gonzalo Nuñez-Marin
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Rafael de la Espriella
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain
| | - Clara Bonanad
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain; Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), Madrid, Spain
| | - Julio Nuñez
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain; Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), Madrid, Spain; Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Francisco Javier Chorro
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain; Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), Madrid, Spain; Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Vicente Bodi
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain; Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), Madrid, Spain; Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Enrique Santas
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain.
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16
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Three-Dimensional Transesophageal Echocardiography in the Diagnosis and Treatment of Mitral Prosthetic Valve Endocarditis—A Narrative Review. Medicina (B Aires) 2021; 58:medicina58010023. [PMID: 35056331 PMCID: PMC8779064 DOI: 10.3390/medicina58010023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 01/10/2023] Open
Abstract
Despite advances in diagnosis, imaging methods, and medical and surgical interventions, prosthetic valve endocarditis (PVE) remains an extremely serious and potentially fatal complication of heart valve surgery. Characteristic changes of PVE are more difficult to detect by transthoracic echocardiography (TTE) than those involving the native valve. We reviewed advances in transesophageal echocardiography (TEE) in the diagnosis of PVE. Three-dimensional (3D) TEE is becoming an increasingly available imaging method combined with two-dimensional TEE. It contributes to faster and more accurate diagnosis of PVE, assessment of PVE-related complications, monitoring effectiveness of antibiotic treatment, and determining optimal time for surgery, sometimes even before or without previous TTE. In this article, we present advances in the treatment of patients with mitral PVE due to 3D TEE application.
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17
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Livesay J, Coombes T, Spoons J, Dolacky S, Shorman M. Comparing Echocardiographic Modalities in Native-Valve Infective Endocarditis Due to Methicillin-Resistant Staphylococcus Aureus in People Who Inject Drugs. Cureus 2021; 13:e19372. [PMID: 34925979 PMCID: PMC8654195 DOI: 10.7759/cureus.19372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients. Methods: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed. Results: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE. Conclusion: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke’s criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.
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Affiliation(s)
- James Livesay
- Department of Cardiovascular Medicine Fellowship, University of Tennessee Graduate School of Medicine, Knoxville, USA
| | - Tyler Coombes
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, USA
| | - Jared Spoons
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, USA
| | - Steven Dolacky
- Department of Cardiology, University of Tennessee Graduate School of Medicine, Knoxville, USA
| | - Mahmoud Shorman
- Department of Infectious Diseases, University of Tennessee Graduate School of Medicine, Knoxville, USA
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Abstract
Purpose of Review Sepsis is a leading cause of death worldwide. Groundbreaking international collaborative efforts have culminated in the widely accepted surviving sepsis guidelines, with iterative improvements in management strategies and definitions providing important advances in care for patients. Key to the diagnosis of sepsis is identification of infection, and whilst the diagnostic criteria for sepsis is now clear, the diagnosis of infection remains a challenge and there is often discordance between clinician assessments for infection. Recent Findings We review the utility of common biochemical, microbiological and radiological tools employed by clinicians to diagnose infection and explore the difficulty of making a diagnosis of infection in severe inflammatory states through illustrative case reports. Finally, we discuss some of the novel and emerging approaches in diagnosis of infection and sepsis. Summary While prompt diagnosis and treatment of sepsis is essential to improve outcomes in sepsis, there remains no single tool to reliably identify or exclude infection. This contributes to unnecessary antimicrobial use that is harmful to individuals and populations. There is therefore a pressing need for novel solutions. Machine learning approaches using multiple diagnostic and clinical inputs may offer a potential solution but as yet these approaches remain experimental.
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19
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Daubenspeck DK, Hackett IS, Patel AR, Chaney MA. Diagnosing Endocarditis: Get the Picture?! J Cardiothorac Vasc Anesth 2021; 36:358-361. [PMID: 34801395 DOI: 10.1053/j.jvca.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Ian S Hackett
- Section of Cardiology, Department of Medicine, University of Chicago Chicago, IL
| | - Amit R Patel
- Cardiac MRI and CT, Department of Medicine and Radiology, University of Chicago Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago Chicago, IL
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20
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Kirkbride RR, Rawal B, Mirsadraee S, Galperin-Aizenberg M, Wechalekar K, Ridge CA, Litmanovich DE. Imaging of Cardiac Infections: A Comprehensive Review and Investigation Flowchart for Diagnostic Workup. J Thorac Imaging 2021; 36:W70-W88. [PMID: 32852420 DOI: 10.1097/rti.0000000000000552] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Infections of the cardiovascular system may present with nonspecific symptoms, and it is common for patients to undergo multiple investigations to arrive at the diagnosis. Echocardiography is central to the diagnosis of endocarditis and pericarditis. However, cardiac computed tomography (CT) and magnetic resonance imaging also play an additive role in these diagnoses; in fact, magnetic resonance imaging is central to the diagnosis of myocarditis. Functional imaging (fluorine-18 fluorodeoxyglucose-positron emission tomography/CT and radiolabeled white blood cell single-photon emission computed tomography/CT) is useful in the diagnosis in prosthesis-related and disseminated infection. This pictorial review will detail the most commonly encountered cardiovascular bacterial and viral infections, including coronavirus disease-2019, in clinical practice and provide an evidence basis for the selection of each imaging modality in the investigation of native tissues and common prostheses.
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Affiliation(s)
- Rachael R Kirkbride
- Department of Cardiothoracic Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | | | - Maya Galperin-Aizenberg
- Department of Radiology Hospital of the University of Pennsylvania and Perelman School of Medicine, Philadelphia, PA
| | - Kshama Wechalekar
- Department of Nuclear Medicine and PET, Royal Brompton and Harefield Foundation Trust Hospital, London, UK
| | | | - Diana E Litmanovich
- Department of Cardiothoracic Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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21
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Lakkas L, Serim BD, Fotopoulos A, Iakovou I, Doumas A, Korkmaz U, Michalis LK, Sioka C. Infection of cardiac prosthetic valves and implantable electronic devices: early diagnosis and treatment. Acta Cardiol 2021; 76:569-575. [PMID: 32406333 DOI: 10.1080/00015385.2020.1761594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There has been a recent rise in the use of implantable cardiac devices, mostly valves but also electronic ones, such as pacemakers, and implantable defibrillators. The increasing use of these devices had as a consequence the raised incidence of endocarditis, an infrequent but morbid complication of these procedures. Thus, early diagnosis of the implantable cardiac devices related infection and endocarditis became pivotal for appropriate management. For diagnostic purposes, the modified Duke criteria are widely used, which are based on clinical and imaging findings, in addition to serological analyses and blood cultures. 18F-fluoro-2-deoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a recently employed method in order to improve the early diagnosis of endocarditis as well as infection of the implantable device. It is likely, that combining the modified Duke criteria with the FDG PET/CT, will increase the sensitivity and specificity of diagnosis and will guide the treating physician to an early and appropriate management.
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Affiliation(s)
- Lampros Lakkas
- 2nd Department of Cardiology, Medical school, University Hospital of Ioannina, Ioannina, Greece
| | - Burcu Dirlik Serim
- Department of Nuclear Medicine, Institution of Cardiology, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Andreas Fotopoulos
- Department of Nuclear Medicine, Medical school, University Hospital of Ioannina, Ioannina, Greece
| | - Ioannis Iakovou
- 2nd Department of Nuclear Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Argyrios Doumas
- 2nd Department of Nuclear Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Ulku Korkmaz
- Department of Nuclear Medicine, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Lampros K. Michalis
- 2nd Department of Cardiology, Medical school, University Hospital of Ioannina, Ioannina, Greece
| | - Chrissa Sioka
- Department of Nuclear Medicine, Medical school, University Hospital of Ioannina, Ioannina, Greece
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22
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Left Ventricular Pseudoaneurysm: Unexpected Finding in a Patient Who Presented With Bacterial Endophthalmitis. JACC Case Rep 2021; 3:932-934. [PMID: 34317658 PMCID: PMC8311265 DOI: 10.1016/j.jaccas.2021.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 12/03/2022]
Abstract
A large left ventricular pseudoaneurysm was discovered in a patient who presented with bacterial endophthalmitis 1 year after medically treated Staphylococcus aureus mitral valve endocarditis. After medical therapy, the patient underwent cardiac surgery uneventfully. We present a rare finding of a pseudoaneurysm complicated with a very late ocular septic event. (Level of Difficulty: Advanced.)
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23
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An Experimental Infective Endocarditis Model in Rats. JOURNAL OF BASIC AND CLINICAL HEALTH SCIENCES 2021. [DOI: 10.30621/jbachs.915263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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De Silva HM, Hewagama S, Strugnell N. Enterococcus faecalis infective endocarditis arising from chronic rectal prolapse in the setting of spinal cord injury. BMJ Case Rep 2021; 14:14/2/e240356. [PMID: 33558386 PMCID: PMC7872921 DOI: 10.1136/bcr-2020-240356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 45-year-old man had recurrent presentations with pleuritic chest pain and shortness of breath. Four months prior, he had developed cauda equina syndrome from a spinal epidural abscess in the setting of intravenous drug use, complicated by lasting neurological deficits and a rectal prolapse. On his final presentation, blood cultures taken in the absence of antibiotics grew Enterococcus faecalis from multiple sets. A transoesophageal echocardiogram confirmed tricuspid valve endocarditis. He recovered well post-targeted long-term antibiotics. Endoscopy confirmed a chronic rectal prolapse with multiple ulcers and was hypothesised as the source of bacteraemia. He subsequently underwent perineal rectosigmoidectomy. This uncommon sequela of rectal prolapse highlights several issues, including the management of neurogenic bowel dysfunction following spinal cord injury and the importance of early prolapse recognition and management. Finally, appropriate collection of blood cultures and correct use of echocardiography are critical steps in investigating infective endocarditis.
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Affiliation(s)
| | - Saliya Hewagama
- Department of General Medicine, The Northern Hospital, Epping, Victoria, Australia
| | - Neil Strugnell
- Department of General Surgery, The Northern Hospital, Epping, Victoria, Australia
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25
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Alshoabi SA, Aljaber NN, Gameraddin MB, Omer AM. Multivalvular destruction as the primary presentation of aggressive infective endocarditis with subaortic valve membrane. Pak J Med Sci 2021; 37:600-604. [PMID: 33679959 PMCID: PMC7931308 DOI: 10.12669/pjms.37.2.2798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Multivalvular destruction may be a clinical manifestation of infective endocarditis (IE), which is a devastating infection of the heart either alone or superimposed with congenital subaortic membrane as in this case report. Here, we report a case of multivavular destruction with severe vegetation presented as a manifestation of infective endocarditis (IE) in a neglected case of 18-year-old male with previous rheumatic heart disease. Transesophageal echocardiography is an important imaging modality for diagnosis of superimposed aortic and heart lesions. Early necessary investigation and correct diagnosis is mandatory to prevent bad complications.
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Affiliation(s)
- Sultan Abdulwadoud Alshoabi
- Sultan Abdulwadoud Alshoabi, Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
| | - Nouradden Noman Aljaber
- Nouradden Noman Aljaber, Department of Medicine, Faculty of Medicine, Sana'a University, Sana'a, Republic of Yemen
| | - Moawia Bushra Gameraddin
- Moawia Bushra Gameraddin, Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
| | - Awatef Mohammed Omer
- Awatef Mohammed Omer, Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
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26
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De Palo M, Scicchitano P, Malvindi PG, Paparella D. Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis. Antibiotics (Basel) 2021; 10:antibiotics10010050. [PMID: 33419074 PMCID: PMC7825452 DOI: 10.3390/antibiotics10010050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/25/2020] [Accepted: 01/03/2021] [Indexed: 12/25/2022] Open
Abstract
The interventional treatment of aortic stenosis is currently based on transcatheter aortic valve implantation/replacement (TAVI/TAVR) and surgical aortic valve replacement (SAVR). Prosthetic valve infective endocarditis (PVE) is the most worrisome complication after valve replacement, as it still carries high mortality and morbidity rate. Studies have not highlighted the differences in the occurrence of PVE in SAVR as opposed to TAVR, but the reported incidence rates are widely uneven. Literature portrays different microbiological profiles for SAVR and TAVR PVE: Staphylococcus, Enterococcus, and Streptococcus are the pathogens that are more frequently involved with differences regarding the timing from the date of the intervention. Imaging by means of transoesophageal echocardiography, and computed tomography (CT) Scan is essential in identifying vegetations, prosthesis dysfunction, dehiscence, periannular abscess, or aorto-ventricular discontinuity. In most cases, conservative medical treatment is not able to prevent fatal events and surgery represents the only viable option. The primary objectives of surgical treatment are radical debridement and the removal of infected tissues, the reconstruction of cardiac and aortic morphology, and the restoration of the aortic valve function. Different surgical options are discussed. Fast diagnosis, the adequacy of antibiotics treatment, and prompt interventions are essential in preventing the negative consequences of infective endocarditis (IE).
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Affiliation(s)
- Micaela De Palo
- Section of Cardiac Surgery, A.O.U. Consorziale Policlinico di Bari, 70124 Bari, Italy
- Correspondence: (M.D.P.); (D.P.); Tel.: +39-080-559-4404 (M.D.P.); +39-080-919-9162 (D.P.)
| | - Pietro Scicchitano
- Section of Cardiology, F. Perinei Hospital, Altamura, 70022 Bari, Italy;
| | | | - Domenico Paparella
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, 70124 Bari, Italy
- Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
- Correspondence: (M.D.P.); (D.P.); Tel.: +39-080-559-4404 (M.D.P.); +39-080-919-9162 (D.P.)
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27
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Bridwell RE, Larson NP, Birdsong S, Long B, Goss S. Native Mitral Valve Infective Endocarditis From Flossing: A Case Report and Emergency Department Management. Cureus 2020; 12:e12144. [PMID: 33489556 PMCID: PMC7813535 DOI: 10.7759/cureus.12144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Infective endocarditis (IE) is a rare, elusive disease, carrying a 10%-30% mortality. Requiring a high index of suspicion, IE affects damaged native valves and prosthetic valves. While there are a number of inherent risk factors that predispose patients to IE, dental work in the preceding six weeks is often a culprit of disease, colonizing damaged native mitral valves with Streptococcus viridans species. Traditionally, flossing has been suggested to be protective against IE. We present a case of S. gordonii subacute IE on a regurgitant native mitral valve secondary to vigorous flossing.
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28
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Cutaneous Vasculitis and Generalized Lymphadenopathy Associated with Extended-Spectrum Beta-Lactamase (ESBL)-Producing Escherichia coli Endocarditis: A Rare Case Report. Infect Dis Ther 2020; 10:583-593. [PMID: 33284398 PMCID: PMC7954929 DOI: 10.1007/s40121-020-00377-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Infective endocarditis (IE) has been known as the great imitator due to variable clinical manifestation, making its diagnosis challenging. A missed diagnosis could lead to inappropriate therapy. We presented a rare case of blood culture-negative infective endocarditis (BCNIE) due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli manifest with cutaneous vasculitis and generalized lymphadenopathy. We highlighted its diagnostic challenge and management. CASE ILLUSTRATION AND DISCUSSION A 36-year-old male with known asymptomatic ruptured sinus of Valsalva (SOV) presented with fever of unknown origin for six months, fatigue, weight loss with a history of multiple hospitalizations. The physical examination revealed a continuous murmur at Erb's point, cutaneous vasculitis, and bilateral inguinal lymphadenopathy. The laboratory result was leukocytosis and elevated C-Reactive Protein (CRP). Generalized lymphadenopathy was detected from the thorax and abdominal Computed Tomography (CT) Scans. Positive Anti Nuclear Antibody (ANA) Indirect Immunofluorescence (IF) speckled pattern led us to consider an autoimmune as the etiology, but we still considered IE as a differential diagnosis due to history of structural heart disease. Detection of multiple tiny oscillating masses at the tricuspid valve from the echocardiogram and cardiac CT led to possible IE diagnosis. Negative three consecutive blood cultures led the diagnosis to BCNIE. Surgery was performed to evacuate the vegetations, repair the SOV, and tricuspid valve replacement with a bioprosthetic valve. These results in improvement of the patient's condition. ESBL-producing Escherichia coli yielded in tissue culture made the diagnosis of IE became definite. CONCLUSION ESBL-producing Escherichia coli should be considered as the etiology of BCNIE. Cutaneous vasculitis and generalized lymphadenopathy as a manifestation of IE could lead to diagnostic confusion. A thorough investigation will help clinician to avoid delay or inappropriate treatment that could be detrimental for the patient.
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Sifaoui I, Oliver L, Tacher V, Fiore A, Lepeule R, Moussafeur A, Huguet R, Teiger E, Audureau E, Derbel H, Luciani A, Kobeiter H, Lim P, Ternacle J, Deux JF. Diagnostic Performance of Transesophageal Echocardiography and Cardiac Computed Tomography in Infective Endocarditis. J Am Soc Echocardiogr 2020; 33:1442-1453. [PMID: 32981789 DOI: 10.1016/j.echo.2020.07.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
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Affiliation(s)
- Henry F Chambers
- From the Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco (H.F.C.); and the Division of Infectious Diseases, Harbor-UCLA (University of California, Los Angeles) Medical Center, and the David Geffen School of Medicine at UCLA, Los Angeles, and the Lundquist Institute, Torrance - both in California (A.S.B.)
| | - Arnold S Bayer
- From the Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco (H.F.C.); and the Division of Infectious Diseases, Harbor-UCLA (University of California, Los Angeles) Medical Center, and the David Geffen School of Medicine at UCLA, Los Angeles, and the Lundquist Institute, Torrance - both in California (A.S.B.)
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Nunes MCP, Ferrari TCA. Mitral-Aortic Intervalvular Fibrosa: A Hidden Region Associated With Infective Endocarditis Complications. JACC Case Rep 2020; 2:1217-1219. [PMID: 34317452 PMCID: PMC8311873 DOI: 10.1016/j.jaccas.2020.05.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Maria Carmo Pereira Nunes
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Teresa Cristina Abreu Ferrari
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Mauro C, Vriz O, Romano L, Citro R, Russo V, Ranieri B, Alamro B, Aladmawi M, Granata R, Galzerano D, Bellino M, Cocchia R, Mehta RM, Dellegrottaglie S, Alsergani H, Mehta RH, Bossone E. Imaging Cardiovascular Emergencies: Real World Clinical Cases. Heart Fail Clin 2020; 16:331-346. [PMID: 32503756 DOI: 10.1016/j.hfc.2020.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Cardiovascular emergencies represent life-threatening conditions requiring a high index of clinical suspicion. In an emergency scenario, a simple stepwise biomarker/imaging diagnostic algorithm may help prompt diagnosis and timely treatment along with related improved outcomes. This article describes several clinical cases of cardiovascular emergencies, such as coronary stent thrombosis-restenosis, takotsubo syndrome, acute myocarditis, massive pulmonary embolism, type A acute aortic dissection, cardiac tamponade, and endocarditis.
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Affiliation(s)
- Ciro Mauro
- Cardiology Division, A Cardarelli Hospital, Via Cardarelli 9, Naples I-80131, Italy
| | - Olga Vriz
- Cardiology Department, Heart Centre, King Faisal Specialist Hospital & Research Centre, MBC-16, PO Box 3354, Riyadh 11211, Saudi Arabia
| | - Luigia Romano
- Department of General and Emergency Radiology, A Cardarelli Hospital, Via Cardarelli 9, Naples I-80131, Italy
| | - Rodolfo Citro
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città d'Ippocrate, Salerno 84131, Italy
| | - Valentina Russo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Pansini 5, Naples I-80131, Italy
| | | | - Bandar Alamro
- Cardiology Department, Heart Centre, King Faisal Specialist Hospital & Research Centre, MBC-16, PO Box 3354, Riyadh 11211, Saudi Arabia
| | - Mohammed Aladmawi
- Cardiology Department, Heart Centre, King Faisal Specialist Hospital & Research Centre, MBC-16, PO Box 3354, Riyadh 11211, Saudi Arabia
| | - Riccardo Granata
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Pansini 5, Naples I-80131, Italy
| | - Domenico Galzerano
- Cardiology Department, Heart Centre, King Faisal Specialist Hospital & Research Centre, MBC-16, PO Box 3354, Riyadh 11211, Saudi Arabia
| | - Michele Bellino
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città d'Ippocrate, Salerno 84131, Italy
| | - Rosangela Cocchia
- Division of Cardiac Rehabilitation - Echo Lab, A Cardarelli Hospital, Naples, Italy
| | - Rahul M Mehta
- ProMedica Monroe Regional Hospital, 718 North Macomb Street, Monroe, MI 48162, USA
| | - Santo Dellegrottaglie
- Division of Cardiology, Clinica Villa dei Fiori, C.so Italia 157, 80011, Acerra, Naples, Italy
| | - Hani Alsergani
- Cardiology Department, Heart Centre, King Faisal Specialist Hospital & Research Centre, MBC-16, PO Box 3354, Riyadh 11211, Saudi Arabia
| | - Rajendra H Mehta
- Duke Clinical Research Institute, Durham, 300 West Morgan Street, Durham, NC 27701, USA
| | - Eduardo Bossone
- Division of Cardiac Rehabilitation - Echo Lab, A Cardarelli Hospital, Naples, Italy.
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Oliveira M, Guittet L, Hamon M, Hamon M. Comparative Value of Cardiac CT and Transesophageal Echocardiography in Infective Endocarditis: A Systematic Review and Meta-Analysis. Radiol Cardiothorac Imaging 2020; 2:e190189. [PMID: 33778583 DOI: 10.1148/ryct.2020190189] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 02/24/2020] [Accepted: 03/11/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE To assess the comparative diagnostic accuracy of cardiac CT and transesophageal echocardiography (TEE) in the detection of valvular and perivalvular complications in infective endocarditis. MATERIALS AND METHODS PubMed and Embase databases were systematically searched until July 2019 for original articles published in English. Studies were included if (a) they used CT and/or TEE as an index test, (b) data were provided as infective endocarditis valvular complications (classified as abscess or pseudoaneurysm, vegetation, leaflet perforation, and paravalvular leakage), and (c) they used surgical findings as the reference standard. RESULTS Eight studies fulfilled the inclusion criteria. The sensitivity was higher for CT than TEE for abscess or pseudoaneurysm detection, 78% (95% confidence interval [CI]: 70%, 85%) (112 of 142) versus 69% (95% CI: 62%, 76%) (94 of 135) (P = .052) and increased to 87% (95% CI: 78%, 93%) (70 of 79) when restricted to multiphase CT studies, the difference being significant (P = .04). The sensitivity was significantly higher for TEE than CT for vegetation detection, 94% (95% CI: 92%, 96%) (363 of 383) versus 64% (95% CI: 57%, 70%) (151 of 237) (P < .001) and leaflet perforation detection, 81% (95% CI: 71%, 88%) (74 of 91) versus 41% (95% CI: 25%, 59%) (14 of 35) (P = .02).The sensitivity for paravalvular leakage was 69% (95% CI: 58%, 79%) (56 of 80) versus 44% (95% CI: 30%, 59%) (21 of 48) for TEE and CT, respectively (P = .27). CONCLUSION CT performs better than TEE in the detection of abscess or pseudoaneurysm whereas TEE gives superior results for vegetation detection, leaflet perforation, and paravalvular leakage.Supplemental material is available for this article.© RSNA, 2020.
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Affiliation(s)
- Magno Oliveira
- Departments of Radiology (M.O., Michèle Hamon) and Medical Information (L.G.), Centre Hospitalier Universitaire de Caen, Avenue Côte de Nacre, 14033 Caen, France; and UFR de Médecine, Université de Caen, Caen, France (M.O., L.G., Martial Hamon, Michèle Hamon)
| | - Lydia Guittet
- Departments of Radiology (M.O., Michèle Hamon) and Medical Information (L.G.), Centre Hospitalier Universitaire de Caen, Avenue Côte de Nacre, 14033 Caen, France; and UFR de Médecine, Université de Caen, Caen, France (M.O., L.G., Martial Hamon, Michèle Hamon)
| | - Martial Hamon
- Departments of Radiology (M.O., Michèle Hamon) and Medical Information (L.G.), Centre Hospitalier Universitaire de Caen, Avenue Côte de Nacre, 14033 Caen, France; and UFR de Médecine, Université de Caen, Caen, France (M.O., L.G., Martial Hamon, Michèle Hamon)
| | - Michèle Hamon
- Departments of Radiology (M.O., Michèle Hamon) and Medical Information (L.G.), Centre Hospitalier Universitaire de Caen, Avenue Côte de Nacre, 14033 Caen, France; and UFR de Médecine, Université de Caen, Caen, France (M.O., L.G., Martial Hamon, Michèle Hamon)
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Serra N, Colomba C, Di Carlo P, Palermo G, Fasciana T, Giammanco A, Novo G, Rea T, Marino MM, Argano V, Sergi C. Infective Endocarditis: Preliminary Results of a Cohort Study in the Southern Italian Population. Cureus 2020; 12:e8338. [PMID: 32617213 PMCID: PMC7325401 DOI: 10.7759/cureus.8338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Infective endocarditis (IE) is an uncommon disease with an involved interplay of clinical and surgical team management. We aimed to define diagnosis parameters and delineate in-hospital management in patients with IE admitted in a tertiary hospital of Southern Italian. Materials and methods Fifty-six consecutive patients (42 males, 14 females; age range: 34-85 years) admitted for IE in the Infectious Diseases, Cardiac Surgery, and Cardiology units, between January 2011 and August 2017, were enrolled. Demographic data, mortality, comorbidities, specimen type, microscopy results, special histological staining performed, and antimicrobial therapy were collected and analyzed. Any comments at the multidisciplinary team meetings were recorded in minutes of and approved. Results We found 83.9% of patients with positive blood cultures. The four most common bacteria were methicillin-resistant Staphylococcus aureus (MRSA: 21.3%), methicillin-sensitive Staphylococcus aureus (MSSA: 17%), Streptococci (14.9%), and Enterococci (14.9%). Both in the univariate and multivariate analysis, we observed a significant positive correlation between surgery and complications. Particularly in the univariate analysis only, surgery was positively correlated to males and C-reactive protein (CPR) at baseline. Also, considering the most common bacteria, it resulted in a positive correlation between surgery and MRSA and Streptococci spp. and between complications and MSSA. Finally, the male gender was positively correlated to MSSA and heart complications, major arterial embolism, septic pulmonary emboli, splenic infarction, and cerebral embolism. Conclusions A blood culture test remains a critical factor for the diagnosis of IE and the antibiotic treatment of susceptible and emerging resistant bacteria. Male gender and heart complications are red flags for prompt operative management.
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Affiliation(s)
- Nicola Serra
- Department of Molecular Medicine and Medical Biotechnology, University Federico II of Naples, Naples, ITA
| | - Claudia Colomba
- Department of Health Promotion, Maternal-Childhood, Internal Medicine of Excellence "G. D'Alessandro," Promise, University of Palermo, Palermo, ITA
| | - Paola Di Carlo
- Department of Health Promotion, Maternal-Childhood, Internal Medicine of Excellence "G. D'Alessandro," Promise, University of Palermo, Palermo, ITA.,Department of Infectious Disease, Policlinico Paolo Giaccone University Hospital, Palermo, ITA
| | - Gabriele Palermo
- Department of Health Promotion, Maternal-Childhood, Internal Medicine of Excellence "G. D'Alessandro," Promise, University of Palermo, Palermo, ITA
| | - Teresa Fasciana
- Department of Microbiology, University of Palermo, Palermo, ITA
| | - Anna Giammanco
- Department of Health Promotion, Maternal-Childhood, Internal Medicine of Excellence "G. D'Alessandro," Promise, University of Palermo, Palermo, ITA
| | - Giuseppina Novo
- Department of Health Promotion, Maternal-Childhood, Internal Medicine of Excellence "G. D'Alessandro," Promise, University of Palermo, Palermo, ITA
| | - Teresa Rea
- Department of Public Health, University of Naples, Naples, ITA
| | - Maria Michela Marino
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, ITA
| | | | - Consolato Sergi
- Medicine and Pathology: Laboratory, University of Alberta, Edmonton, CAN
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Applications of a Specialty Bicuspid Aortic Valve Program: Clinical Continuity and Translational Collaboration. J Clin Med 2020; 9:jcm9051354. [PMID: 32380775 PMCID: PMC7290776 DOI: 10.3390/jcm9051354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
Bicuspid aortic valve (BAV) is a common congenital heart diagnosis and is associated with aortopathy. Current guidelines for aortic resection have been validated but are based on aortic diameter, which is insufficient to predict acute aortic events. Clinical and translational collaboration is necessary to identify biomarkers that can individualize the timing of prophylactic surgery for BAV aortopathy. We describe our multidisciplinary BAV program, including research protocols aimed at biomarker discovery and results from our longitudinal clinical registry. From 2012–2018, 887 patients enrolled in our clinical BAV registry with the option to undergo four dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) and donate serum plasma or tissue samples. Of 887 patients, 388 (44%) had an elective BAV-related procedure after initial presentation, while 499 (56%) continued with medical management. Of medical patients, 44 (9%) had elective surgery after 2.3 ± 1.4 years. Surgery patients’ biobank donations include 198 (46%) aorta, 374 (86%) aortic valve, and 314 (73%) plasma samples. The 4D flow CMR was completed for 215 (50%) surgery patients and 243 (49%) medical patients. Patients with BAV aortopathy can be safely followed by a multidisciplinary team to detect indications for surgery. Paired tissue and hemodynamic analysis holds opportunity for biomarker development in BAV aortopathy.
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Rempfer E, Basinger H, Stawovy L, End B, Shockcor W, Minardi J. MitraClip-Associated Endocarditis: Emergency Department Diagnosis With Point of Care Ultrasound. J Emerg Med 2020; 58:942-946. [PMID: 32247658 DOI: 10.1016/j.jemermed.2020.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/15/2020] [Accepted: 02/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Management of mitral valve regurgitation in patients with multiple comorbidities is complicated because of poor surgical candidacy. Less invasive techniques for these patients include the MitraClip device, an endovascular repair option used to reduce mitral valve regurgitation symptoms. However, complications include leaflet damage, stenosis, and infectious endocarditis. CASE REPORT Four years after MitraClip placement, an 80-year-old man presented to the emergency department with progressive dyspnea. He was diagnosed with MitraClip-associated infectious endocarditis by the emergency physician using point-of-care ultrasound. There are 6 reported cases of infective endocarditis in patients with MitraClip devices, with this being the first case identified using point-of-care ultrasound. This is also the first reported case of MitraClip-associated Corynebacterium endocarditis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The use of the MitraClip device and its echocardiographic appearance is not widely described in the published emergency medicine literature. Knowledge of this device, its appearance, and the potential complications is essential for emergency physicians caring for these patients. Rapid diagnosis may lead to earlier initiation of treatment and optimal disposition for these complex patients.
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Affiliation(s)
- Elizabeth Rempfer
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Hayden Basinger
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Lauren Stawovy
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Bradley End
- Department of Emergency Medicine, West Virginia University, Morgantown, West Virginia
| | - William Shockcor
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Joseph Minardi
- Department of Emergency Medicine, West Virginia University, Morgantown, West Virginia
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Galzerano D, Kinsara AJ, Di Michele S, Vriz O, Fadel BM, Musci RL, Galderisi M, Al Sergani H, Colonna P. Three dimensional transesophageal echocardiography: a missing link in infective endocarditis imaging? Int J Cardiovasc Imaging 2020; 36:403-413. [PMID: 31902093 DOI: 10.1007/s10554-019-01747-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
Abstract
The role of two dimensional (2D) echocardiography (ECHO) for the diagnosis and clinical decision making in infective endocarditis (IE) has been extensively studied and described in the medical literature. Some reports have demonstrated the incremental value of three dimensional (3D) transesophageal (TE) ECHO in the setting of IE. However, a systematic review focusing on the role of 3D imaging is lacking. In this manuscript, we examine the role of 3D TE ECHO in the diagnosis of IE. IE is a challenging disease in which 2D transthoracic (TT) and TE ECHO have complementary roles and are unequivocally the mainstay of diagnostic imaging. Still, 2D imaging has important limitations. Technological advances in 3D imaging allow for the reconstruction of real-time anatomical images of cardiac structure and function. 3D imaging has emerged as a diagnostic technique that overcame some of the limitations of 2D ECHO. Currently, both transthoracic and transesophageal echocardiography transducers are able to generate 3D images. However, 3D TE ECHO provides images of a higher quality in comparison to 3D TT ECHO, and is the best echocardiographic modality able to allow for a detailed anatomical imaging. 3D TE ECHO may represent the key adjunctive echocardiographic technique being able to positively impact on IE-related surgical planning and intervention and to facilitate the interaction between the surgeon and the imaging specialist. Importantly, 3D TE ECHO is not the recommended initial modality of choice for the diagnosis of IE; however, in highly specialized centers, it has become an important complementary technique when advanced surgical planning is required. Furthermore, anatomical imaging has become the link between the different techniques that play a role in IE imaging. In fact, both computed tomography and magnetic resonance allow three dimensional reconstruction. An important future goal should allow for the fusion among various imaging modalities. Our review highlights the role of 3D TE ECHO in IE imaging and emphasize where it offers incremental value.
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Affiliation(s)
- Domenico Galzerano
- The Heart Centre, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia. .,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Abdulhalim J Kinsara
- Ministry of National Guard Health Affair, COM-WR, King Abdullah International Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Sara Di Michele
- Divisione di Cardiologia, Ospedale San Filippo Neri, Rome, Italy
| | - Olga Vriz
- The Heart Centre, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Bahaa M Fadel
- The Heart Centre, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Rita Leonarda Musci
- Ecocardiografia Basale e Complessa, Azienda Ospedaliera Universitaria, Policlinico di Bari, Bari, Italy
| | - Maurizio Galderisi
- Department of Cardiology, Cardiac Surgery and Cardiovascular Emergencies, Federico II, University of Naples, Naples, Italy
| | - Hani Al Sergani
- The Heart Centre, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Paolo Colonna
- Ecocardiografia Basale e Complessa, Azienda Ospedaliera Universitaria, Policlinico di Bari, Bari, Italy
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Seifert M, Möller V, Claus T, Hölschermann F, Butter C. [Septicemia and endocarditis with multiple implants : CIED, TAVI, MK clip and LAA occluders]. Herzschrittmacherther Elektrophysiol 2019; 30:197-203. [PMID: 30969355 DOI: 10.1007/s00399-019-0618-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 03/24/2019] [Indexed: 11/27/2022]
Abstract
Infective endocarditis (IE) as well as septicemia in patients with implanted cardiac devices are severe diseases and diagnosis is often delayed due to a variety of misleading symptoms. Imaging with transesophageal echocardiography (TEE) and also microbiology play a key role in both the diagnosis and management. They are also useful for the prognostic assessment of patients with IE, for follow-up during treatment, during extraction of the implant and after surgery. In addition to antibiotic treatment, removal of the implant is also necessary, at least if vegetation is detected. Not only the removal of the implant but also the underlying cardiac disease, the frequently occurring severe cardiac insufficiency, the advanced age and the not uncommon high degree of fragility of the patients mean that decision making for treatment and management as well as renewed implantation after completion of treatment are a challenge. The optimal treatment is only possible with a close cooperation between various specialist disciplines and should therefore be carried out in experienced centers.
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Affiliation(s)
- M Seifert
- Abteilung für Kardiologie, Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Str. 17, 16321, Bernau, Deutschland.
| | - V Möller
- Abteilung für Kardiologie, Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Str. 17, 16321, Bernau, Deutschland
| | - T Claus
- Abteilung für Herzchirurgie, Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Str. 17, 16321, Bernau, Deutschland
| | - F Hölschermann
- Abteilung für Kardiologie, Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Str. 17, 16321, Bernau, Deutschland
| | - C Butter
- Abteilung für Kardiologie, Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Str. 17, 16321, Bernau, Deutschland
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Shao S, Guo X, Guo P, Cui Y, Chen Y. Roseomonas mucosa infective endocarditis in patient with systemic lupus erythematosus: case report and review of literature. BMC Infect Dis 2019; 19:140. [PMID: 30755159 PMCID: PMC6373168 DOI: 10.1186/s12879-019-3774-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background Roseomonas mucosa, as a Gram-negative coccobacilli, is an opportunistic pathogen that has rarely been reported in human infections. Here we describe a case of bacteremia in an infective endocarditis patient with systemic lupus erythematosus (SLE). Case presentations A 44-year-old female patient with SLE suffered bacteremia caused by Roseomonas mucosa complicated with infective endocarditis (IE). The patient started on treatment with piperacillin-tazobactam and levofloxacin against Roseomonas mucosa, which was switched after 4 days to meropenem and amikacin for an additional 2 weeks. She had a favorable outcome with a 6-week course of intravenous antibiotic therapy. Discussion and conclusions Roseomonas mucosa is rarely reported in IE patients; therefore, we report the case in order to improve our ability to identify this pathogen and expand the range of known bacterial causes of infective endocarditis.
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Affiliation(s)
- Shayuan Shao
- Department of Laboratory Medicine, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518000, Guangdong, China
| | - Xin Guo
- Department of Laboratory Medicine, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Penghao Guo
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Yingpeng Cui
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Yili Chen
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.
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Sobreiro DI, Sampaio RO, Siciliano RF, Brazil CVA, Branco CEDB, Lopes ASDSA, Tarasoutchi F, Strabelli TMV. Early Diagnosis and Treatment in Infective Endocarditis: Challenges for a Better Prognosis. Arq Bras Cardiol 2019; 112:201-203. [PMID: 30785586 PMCID: PMC6371822 DOI: 10.5935/abc.20180270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/08/2018] [Accepted: 09/05/2018] [Indexed: 02/03/2023] Open
Affiliation(s)
- Daniely Iadocico Sobreiro
- Unidade Clínica de Cardiopatias Valvares do Instituto do
Coração do Hospital das Clínicas da Faculdade de Medicina da
Universidade de São Paulo, São Paulo, SP - Brazil
| | - Roney Orismar Sampaio
- Unidade Clínica de Cardiopatias Valvares do Instituto do
Coração do Hospital das Clínicas da Faculdade de Medicina da
Universidade de São Paulo, São Paulo, SP - Brazil
| | - Rinaldo Focaccia Siciliano
- Unidade de Controle de Infecção Hospitalar do
Instituto do Coração do Hospital das Clínicas da Faculdade de
Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Calila Vieira Andrade Brazil
- Unidade Clínica de Cardiopatias Valvares do Instituto do
Coração do Hospital das Clínicas da Faculdade de Medicina da
Universidade de São Paulo, São Paulo, SP - Brazil
| | - Carlos Eduardo de Barros Branco
- Unidade Clínica de Cardiopatias Valvares do Instituto do
Coração do Hospital das Clínicas da Faculdade de Medicina da
Universidade de São Paulo, São Paulo, SP - Brazil
| | - Antônio Sergio de Santis Andrade Lopes
- Unidade Clínica de Cardiopatias Valvares do Instituto do
Coração do Hospital das Clínicas da Faculdade de Medicina da
Universidade de São Paulo, São Paulo, SP - Brazil
| | - Flávio Tarasoutchi
- Unidade Clínica de Cardiopatias Valvares do Instituto do
Coração do Hospital das Clínicas da Faculdade de Medicina da
Universidade de São Paulo, São Paulo, SP - Brazil
| | - Tânia Mara Varejão Strabelli
- Unidade de Controle de Infecção Hospitalar do
Instituto do Coração do Hospital das Clínicas da Faculdade de
Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
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41
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Sordelli C, Fele N, Mocerino R, Weisz SH, Ascione L, Caso P, Carrozza A, Tascini C, De Vivo S, Severino S. Infective Endocarditis: Echocardiographic Imaging and New Imaging Modalities. J Cardiovasc Echogr 2019; 29:149-155. [PMID: 32089994 PMCID: PMC7011492 DOI: 10.4103/jcecho.jcecho_53_19] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Infective endocarditis (IE) is a rare disease with a significant impact and an increasing mortality despite earlier diagnosis and surgical intervention. It is related to several and the main etiological agents are the Gram-positive cocci. The new guidelines propose new diagnostic criteria that consider the potentiality on integrated multimodality imaging. Echocardiography (TTE) plays a key role for the diagnosis of IE and must be performed as soon as IE is suspected. It allows to identify vegetation, abscess, new dehiscence of prosthetic valve and assesses the number, size, shape, location, echogenicity and mobility of vegetations so it also useful for prediction embolic risk. Transesophageal echocardiography (TEE) is indicated when TTE is positive or non diagnostic, in case of suspected complications and when intracardiac device leads are present. We underline the increasing role of three-dimensional (3D) echocardiography in overcoming the limit of 2DTEE in selecting the maximum true diameter of irregular masses (ie, vegetation). We also underline the diagnostic value of multislice computed tomograpfy (MSCT), cerebral magnetic resonance (RMI) and nuclear imaging and also emphasize the emerging role of particular types of endocarditis specially Lead Endocarditis. The aim of this review is to provide an overview of the imaging techniques useful for the diagnosis and identification of any complications. In our opinion, the management of IE is complex, based on an “Endocarditis team “ composed by several specialist and an integrated multimodality imaging is essential for the diagnostic approach.
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Affiliation(s)
- Chiara Sordelli
- Department of Cardiology, AORN Ospedali dei Colli-Cotugno, Naples, Italy
| | - Nunzia Fele
- Department of Cardiology, AORN Ospedali dei Colli-Cotugno, Naples, Italy
| | - Rosa Mocerino
- Department of Cardiology, AORN Ospedali dei Colli-Cotugno, Naples, Italy
| | - Sara Hana Weisz
- Department of Cardiology, AORN Ospedali dei Colli-Cotugno, Naples, Italy
| | - Luigi Ascione
- Department of Cardiology, AORN Ospedali dei Colli-Monaldi, Naples, Italy
| | - Pio Caso
- Department of Cardiology, AORN Ospedali dei Colli-Monaldi, Naples, Italy
| | - Antonio Carrozza
- Department of Cardiothoracic Surgery, Second University of Naples, Naples, Italy
| | - Carlo Tascini
- Department of Infectious Disease, AORN Ospedali dei Colli-Cotugno, Naples, Italy
| | - Stefano De Vivo
- Department of Cardiology, AORN Ospedali dei Colli-Monaldi, Naples, Italy
| | - Sergio Severino
- Department of Cardiology, AORN Ospedali dei Colli-Cotugno, Naples, Italy
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42
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Bin Abdulhak AA, Qazi AH, Tleyjeh IM. Workup and Management of Native and Prosthetic Valve Endocarditis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:73. [PMID: 30083823 DOI: 10.1007/s11936-018-0668-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Infective endocarditis (IE) is associated with significant serious adverse outcomes including death. IE usually presents with diverse clinical picture and syndromic diagnoses including heart failure, stroke, and peripheral embolization. Given variable, vague, and syndromic presentations, the diagnosis of IE may be delayed for days to weeks. Maintaining a high index of suspicion among clinicians is the key to early recognition of the disease and prompt initiation of antimicrobial therapy to prevent IE-associated mortality and morbidity. Blood culture and echocardiography remain essential tools in the diagnosis of infective endocarditis. However, advances in molecular techniques, serology testing, computed tomography scan, and nuclear medicine have led to growth in the available tools that may aid in early diagnosis of infective endocarditis. Antimicrobial agents are the mainstay of IE therapy; however, as many as 50% of endocarditis cases will undergo valve surgery, even on an urgent or emergent basis.
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Affiliation(s)
- Aref A Bin Abdulhak
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA
| | - Abdul H Qazi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA
| | - Imad M Tleyjeh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA. .,Division of Epidemiology, Mayo Clinic, Rochester, MN, USA. .,Department of Medicine, Infectious Diseases Section, King Fahad Medical City, PO Box 59046, Riyadh, 11525, Saudi Arabia. .,College of Medicine, Al Faisal University, Riyadh, Saudi Arabia.
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