Socio-economic variations in the clinical presentation, etiology and outcome of infective endocarditis in the ESC-EORP EURO-ENDO (European Infective Endocarditis) registry: a prospective cohort study

Background

Infective endocarditis (IE) is a life threatening disease associated with high mortality and morbidity worldwide. We sought to determine how socio-economic factors may influence variations in epidemiology, clinical presentation, investigation and management (and their consequence upon clinical outcomes) in a large international multi-centre registry.

Methods

The ESC-EORPEURO-ENDO registry comprises a prospective cohort of 3116 adult patients admitted to 156 hospitals in 40 countries with IE between January 2016 and March 2018. We analysed the complete dataset to assess potentially important determinants of variation according to World Bank economic stratification (high income (Group 1) [73.8%]; upper-middle income (Group 2) [17.1%]; lower-middle income (Group 3)[9.1%]).

Results

Patients in Group 3 were younger (median age [IQR]: Group 1 - 66 [54–75] years; Group 2 - 57 [40–68] years; Group 3 - 33 [26–43] years; p<0.001) with a higher prevalence of smoking, intravenous drug use and human immunodeficiency virus (HIV) infection (all p<0.001). Group 3 patients with IE presented later (median [IQR) days since symptom onset: Group 1 - 12 [3–35]; Group 2 - 20 [6–51]; Group 3 - 31 [12–62]; p<0.001) and were more likely to develop congestive heart failure (13.6%; 11.3%; and 22.6%, respectively; p<0.001), septic shock (8.3%; 11.1%; 13.4%; p=0.007), and persistent fever for greater than 7 days (9.6%; 14.4%; 27.9%; p<0.001) following hospital admission. Surgery was performed less frequently in Group 3 (75.4%, 76.8% and 51.3% in Groups 1, 2 and 3, respectively; p<0.001) and mortality was highest in the poorest countries (14.6%; 23.6% and 23.7%, respectively; p<0.001).

Conclusion

Socio-economic factors influence the clinical profile of patients presenting with IE across the world. Despite being younger, patients from the poorest countries presented with more frequent complications and higher mortality associated with delayed diagnosis and less frequent use of surgery.

Funding Acknowledgement

Type of funding sources: None.

Mitral regurgitation in acute heart failure: prevalence and response to treatment

 

Heart failure (HF) affects an estimated 90 000 people within the UK. As a consequence of ventricular remodelling, mitral regurgitation (MR) is common in patients with HF, further contributing to poor prognosis, frequent hospitalisation, and higher rates of mortality. Conventional treatment options include medical therapy, cardiac resynchronisation and conventional mitral valve surgery, with transcatheter mitral valve repair (TMVR) reserved for symptomatic patients with left ventricular dysfunction and multiple comorbidities, considered high surgical risk.

Aim

Our objectives were to determine: (1) the proportion of patients with an acute HF admission, ejection fraction (EF) of <50% and moderate or more MR; (2) the effectiveness of optimal medical therapy (OMT) in reducing the severity of MR and symptoms; (3) the number of patients with moderate or more MR, EF <50% and symptoms despite OMT.

Method

We performed a retrospective analysis of patients who presented with acute HF to two large tertiary centres over a five-year period. Based on a combination of electronic care records, and national registry and mortality data, we determined baseline symptoms, symptom progression, and co-morbidities. Echocardiography data was used to assess the degree of MR and EF. Where patients underwent a subsequent echocardiogram on OMT, the change in the degree of MR, EF and symptoms (NYHA class) was examined.

Results

Over a five-year period (Jan 2012–Dec 2017), 1884 patients presented with acute HF. Of this cohort, 302 (16%) had moderate or more MR and EF of <50%. Mortality amongst patients with moderate or more MR was 29.9% at one year (compared to 26.9% for those with less than moderate MR, p=0.058). Of this cohort, 45% had sufficient clinical and echocardiographic paired follow up data to enable assessment of the effects of OMT (Age 78±20.78; Male n=76 (56.3%). This analysis showed, despite OMT, all 135 patients still had moderate or more MR. When compared with previous echocardiography data, 11 (8%) patients showed a reduction in the severity of MR which meant 92% (124) of patient with MR either saw no improvement or worsening of their MR severity. Of those with severe MR, 23% (7) demonstrated an improvement in the degree of MR following OMT. Clinically 70 (51.4%) patients had an improvement in symptoms. There was significant improvement in the NYHA class pre and post optimisation of medical therapy (p<0.001) across all grades of MR. Despite OMT, 124 (92%) patients with moderate or more MR and EF <50% remained symptomatic.

Conclusions

A large portion of patients who present with acute HF have moderate or more MR. Although medical therapy is effective in providing some relief from symptoms, the large majority of patients continue to have moderate or more MR. We propose a portion of these patients are potential candidates for TMVR, and should be considered for further intervention.

Funding Acknowledgement

Type of funding source: None

P2746Survival of people with valvular heart disease in the community (OxValve-Survive)

Background

Valvular heart disease (VHD) occurs commonly in older patients (>65 years) but the majority is mild disease, which is of uncertain importance. Understanding the impact of VHD on mortality in this older group of patients would help determine its relevance and aid the appropriate use of healthcare resources. OxValve is a cohort study in Oxfordshire screening people aged 65 and over for VHD. Over 4,009 participants were recruited between August 2009 and May 2016 and screened using echocardiography to establish the presence and severity of VHD.

AIMS To report survival in the OxValve cohort, and to investigate whether people with VHD are at increased risk of death.

Methods

The OxValve cohort was linked to Office for National Statistics mortality data to obtain date and cause of death. Cox regression was used to investigate the association of any VHD, VHD of significant severity, and VHD subtypes with all-cause and cause-specific mortality, adjusting for potential confounders including age, sex, socioeconomic status, smoking, and comorbidities.

Results

Linked mortality data was available for 3,511 OxValve participants up to September 2018 (median 5.85 years follow-up). VHD was present in 2,645 (75.3%) participants and of these 288 (8.2%) had significant VHD. In total, 311 (8.9%) participants had died. Cancer was the commonest cause of death (n=135), followed by cardiovascular disease (n=75) and respiratory disease (n=35). After adjustment for age and other covariates, mild to moderate VHD was not associated with increased all-cause mortality (HR 1.16, 95% CI: 0.89 to 1.50). However, VHD of significant severity (moderate or severe disease) was associated with a nearly two-fold higher risk of death overall (HR 1.92, 95% CI: 1:38 to 2.67) including increased CVD mortality (HR 2.25, 95% CI: 1.21 to 4.18).

DISCUSSION Mild to moderate VHD was very common, but was not associated with increased mortality. Significant VHD was however associated with a two-fold reduction in survival. Further research is required to understand the natural history of VHD, how to identify those with progressive disease and when to intervene.

Acknowledgement/Funding

NIHR Biomedical Research Centre, Oxford

Infective endocarditis in the military patient

Infective endocarditis (IE) is a potentially fatal cardiac infection associated with an inhospital mortality rate of up to 22%. Fifty per cent of IE cases develop in patients with no known history of valve disease. It is therefore important to remain vigilant to the possibility of the diagnosis in patients with a febrile illness and unknown source. From a military perspective, our patients are unique due to the breadth of pathogens they are exposed to, and blood-culture-negative IE is a risk. In particular, there should be awareness of Coxiella burnetii as a possible causative pathogen. In this review we incorporate the latest consensus from systematic reviews and publications identified by a literature search through Medline. We describe the diagnosis and management of IE with particular reference to the military population.

NICE guidance on antibiotic prophylaxis to prevent infective endocarditis: a survey of clinicians' attitudes

BACKGROUND

Since the introduction of the National Institute for Health and Clinical Excellence (NICE) guideline (CG064) in 2008 recommending cessation of antibiotic prophylaxis (AP) against infective endocarditis (IE), low level prescribing persists in the UK and is a potential reason why there has been no significant change in the general upward trend in cases of IE.

AIM

To undertake a survey of dentists (Ds), cardiologists and cardiothoracic surgeons (C/CTSs) and infection specialists (ISs) to determine why this might be the case.

DESIGN

Internet questionnaire-based survey.

METHODS

A questionnaire was distributed by email to specialists via UK national societies.

RESULTS

A total of 1168 responses were received. All the specialist groups are aware of the guideline (99%). Ds are broadly satisfied, whereas C/CTSs are not. Most Ds follow the NICE guidance (87%), whereas many C/CTSs (39%) do not; ISs adopt a middle course (56%). Even amongst Ds, a significant proportion believe that patients with a prosthetic heart valve (25%) or previous history of IE (38%) should receive AP. A total of 36% of Ds have prescribed AP since March 2008 and many have undertaken procedures where AP has been prescribed by someone else. The majority of respondents (65%) feel that more evidence is required, preferably in the form of a randomized controlled trial.

CONCLUSION

Many patients perceived to be at high risk of IE are still receiving AP in conflict with current NICE guidance.

Evaluation of a wireless ingestible temperature probe in cardiac surgery

OBJECTIVES

CorTemp is a wireless intestinal temperature monitoring system in the form of an ingestible pill and an external receiver. The aim of the study was to evaluate the system's accuracy and practicality during cardiac surgery.

METHODS

A repeat measures design using simultaneous temperature readings from the pulmonary artery (T (pa)), a nasopharyngeal thermometer (T (np)), skin thermometers (T (sk)) and the CorTemp system (T (in)), was conducted in 15 patients undergoing elective cardiac surgery under hypothermic conditions.

RESULTS

Only 67 % of patients' data was analysed and the statistical analysis of a total of 264 sets of readings showed a clinically significant temperature difference of T (in) compared to the other thermometers with limits of agreement between T (in) and T (pa), T (np) and T (sk) (+/- 0.35 to +/- 1.53 degrees C), (+/- 0.72 to +/- 1.63 degrees C) (+/- 0.40 to +/- 1.84 degrees C), respectively. The T (in) bias was significantly different from that of T (pa) ( P = 0.0023), T (np) ( P = 0.018) and T (sk) ( P = 0.0005) during rewarming. The T (in) rate of temperature change was also found to be significantly slower during the rewarming period.

CONCLUSIONS

The significant temperature differences detected during rewarming urge caution regarding CorTemp use as an accurate estimator of brain temperature in cardiac surgery. Further studies are required to assess its potentially useful role as a body core and intestinal temperature monitoring system and as a useful adjunct in investigating bowel ischaemia aetiology in cardiac surgery.

Transoesophageal echocardiographic assessment of mitral valve commissural morphology predicts outcome after balloon mitral valvotomy

OBJECTIVE

To investigate the value of transoesophageal echocardiography in the assessment of commissural morphology and prediction of outcome after balloon mitral valvotomy (BMV).

DESIGN

Prospective study.

SETTING

Tertiary cardiac referral centre.

PATIENTS

72 consecutive patients (mean age 61.3 years, range 38-89 years) referred for BMV.

INTERVENTIONS

Transoesophageal echocardiography was performed immediately before BMV and the mitral commissures were scanned systematically. Anterolateral and posteromedial commissures were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2). Calcified commissures usually resist splitting and scored 0. Scores for each commissure were combined giving an overall commissure score for each valve of 0-4, higher scores reflecting increased likelihood of commissural splitting. Valve anatomy was also graded by the method of Wilkins et al, which does not include commissural assessment.

MAIN OUTCOME MEASURES

Patients were divided into outcome groups: A (good) and B (suboptimal). "Good" was defined as final valve area > 1.5 cm2 with a > 25% increase in area and absence of severe mitral regurgitation judged by echocardiography.

RESULTS

Valve area increased from a mean (SD) of 1.1 (0.28) cm2 to 1.8 (0.46) cm2. Commissure scores were higher in group A than in group B (p < 0.01), scores > or = 2 predicting a good outcome with positive and negative accuracy of 67% and 82%, respectively (p < 0.001). Commissure score was the strongest independent predictor of outcome.

CONCLUSION

Transoesophageal echocardiographic assessment of commissural morphology predicts outcome after BMV, adding significantly to the Wilkins score.

Are the perioperative changes of serum magnesium in lung surgery arrhythmiogenic?

PURPOSE

To prospectively study the perioperative changes in serum magnesium (sMg) after major lung resections and their effect to the generation of cardiac dysrhythmias, and to present a brief review of the literature surrounding this phenomenon.

PATIENTS AND METHODS

We studied 33 patients with non small cell lung cancer (NSCLC), scheduled for major pulmonary resection. Three patients were excluded from the study due to preoperative medication with beta-blocker and calcium (Ca) antagonists. Pneumonectomy was performed in 10 patients and lobectomy in 20. Heparinized arterial blood samples for the assessment of sMg, potassium (K) and Ca concentration were obtained before surgery, on arrival to the High Dependency Unit (HDU), and on the morning of the first and the second postoperative day. No patient had evidence of cardiac disease.

RESULTS

Atrial fibrillation occurred in 3 (10%) patients. There was no statistically significant association between sMg and dysrhythmias. A statistically significant difference after adjusting for age was found between sMg concentration, just after the operation and the first post-operative day and the baseline measurement (before the operation). The type of surgical procedure was not found to be associated with the sMg concentration or the appearance of dysrhythmia. The serum K and Ca concentration for all samples was within normal range.

CONCLUSION

Serum concentration of Mg decreases significantly within the first 24 hours of major lung resection. Although our study didn't demonstrate a relationship between decreases in sMg and the generation of arrhythmias, this link is well established in other fields and thus we support the prophylactic MgSO(4) administration in their prevention in such cases whilst we await further larger studies.

Multivariate prediction of major adverse cardiac events after 9914 percutaneous coronary interventions in the north west of England

OBJECTIVE

To develop a multivariate prediction model for major adverse cardiac events (MACE) after percutaneous coronary interventions (PCIs) by using the North West Quality Improvement Programme in Cardiac Interventions (NWQIP) PCI Registry.

SETTING

All NHS centres undertaking adult PCIs in north west England.

METHODS

Retrospective analysis of prospectively collected data on 9914 consecutive patients undergoing adult PCI between 1 August 2001 and 31 December 2003. A multivariate logistic regression analysis was undertaken, with the forward stepwise technique, to identify independent risk factors for MACE. The area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow goodness of fit statistic were calculated to assess the performance and calibration of the model, respectively. The statistical model was internally validated by using the technique of bootstrap resampling.

MAIN OUTCOME MEASURES

MACE, which were in-hospital mortality, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accidents.

RESULTS

Independent variables identified with an increased risk of developing MACE were advanced age, female sex, cerebrovascular disease, cardiogenic shock, priority, and treatment of the left main stem or graft lesions during PCI. The ROC curve for the predicted probability of MACE was 0.76, indicating a good discrimination power. The prediction equation was well calibrated, predicting well at all levels of risk. Bootstrapping showed that estimates were stable.

CONCLUSIONS

A contemporaneous multivariate prediction model for MACE after PCI was developed. The NWQIP tool allows calculation of the risk of MACE permitting meaningful risk adjusted comparisons of performance between hospitals and operators.

Clinical and haemodynamic profiles of young, middle aged, and elderly patients with mitral stenosis undergoing mitral balloon valvotomy

OBJECTIVE

To compare the clinical characteristics, haemodynamic findings, and symptomatic outcome in four age groups of patients in the UK undergoing percutaneous mitral balloon valvotomy.

DESIGN

A review of patients with mitral stenosis treated by balloon dilatation.

SETTING

Western General Hospital, Edinburgh, a cardiac referral centre.

RESULTS

Of 405 patients who had mitral balloon valvotomy, 19 were aged under 40 years, 101 aged 40-54, 173 aged 55-69, and 112 were 70 years old or more. Medical co-morbidity and Parsonnet score for risk at surgery increased notably with age. Older patients had greater symptomatic limitation and a more severe degree of mitral stenosis, with more valve degenerative change. The incidence of atrial fibrillation, mitral reflux, left ventricular impairment, coronary artery disease, and aortic valve disease increased progressively with age. Before balloon dilatation the right ventricular systolic and left atrial pressures were similar in all age groups, but younger patients had a higher transmitral gradient and cardiac output. After balloon dilatation the younger patients achieved a greater increase in valve area. Complications of balloon valvotomy were more common in the older patients. At five years after balloon dilatation the percentages of patients in each age group who were in New York Heart Association classes I and II were 87%, 63%, 36%, and 19%, respectively. Mortality at five years was 0%, 5%, 31%, and 59%.

CONCLUSIONS

Percutaneous balloon valvotomy gives a good haemodynamic and symptomatic result in patients under 55. In older patients improvement is often less pronounced and less sustained, but the procedure is a well tolerated palliative treatment for those unsuitable for surgery.

Orthotopic heart transplantation with concurrent aortic valve replacement and coronary artery bypass grafting

We report a case of successful orthotopic heart transplantation of a donor heart with normal ventricular function, 2-vessel coronary artery disease, and a bicuspid aortic valve, which required concurrent aortic valve replacement and coronary artery bypass grafting. In confronting the disparities in demand and supply, we must consider the so-called marginally acceptable heart for either critically ill recipients or those who may be disadvantaged on the waiting list.

Early therapeutic experience with the endothelin antagonist BQ-123 in pulmonary hypertension after congenital heart surgery

OBJECTIVE

To assess the effect of endothelin type A (ET(A)) receptor antagonism in infants with pulmonary hypertension following corrective surgery for congenital heart disease.

DESIGN

Open label, preliminary study.

SETTING

Tertiary paediatric cardiothoracic surgical centre.

PATIENTS

Three infants (aged 3 weeks, 7 weeks, and 8 months) with postoperative pulmonary hypertension unresponsive to conventional treatment, including inhaled nitric oxide.

INTERVENTIONS

Patients received incremental intravenous infusions (0.1 to 0.3 mg/kg/h) of the ET(A) receptor antagonist BQ-123.

MAIN OUTCOME MEASURES

The response to BQ-123 administration was determined using continuous invasive monitoring of cardiorespiratory variables.

RESULTS

BQ-123 infusion caused a reduction in the ratio of pulmonary to systemic pressures (0.62 (0.01) to 0.52 (0.03), mean (SEM)) with an accompanying decrease in right ventricular stroke work index (4.6 (0.4) to 2.5 (0.3) g/m) and a tendency for the cardiac index to rise (2.1 (0.2) to 2.7 (0.6) l/min/kg/m(2)). This was associated with a well tolerated fall in the arterial partial pressure of oxygen (16.5 (4.1) to 12.4 (3.3) kPa) and mean systemic arterial pressure (57 (3) to 39 (3) mm Hg).

CONCLUSIONS

ET(A) receptor antagonism in infants with postoperative pulmonary hypertension after corrective surgery for congenital heart disease led to significant improvement in pulmonary haemodynamic indices. However, these benefits were associated with reductions in systemic blood pressure and arterial oxygen saturation, the latter consistent with a ventilation-perfusion mismatch. On the basis of these results, studies in pulmonary hypertension will need to proceed with caution.

Myocardial bradykinin production during coronary balloon angioplasty in humans

BACKGROUND

Recent studies have implicated the peptide bradykinin as a potential trigger of ischaemic preconditioning, the phenomenon whereby a brief episode of myocardial ischaemia induces an increased tolerance to subsequent more prolonged ischaemia. Brief myocardial ischaemia occurring during percutaneous transluminal coronary balloon angioplasty in humans is reported to be capable of inducing preconditioning.

DESIGN

We studied the intracardiac production of bradykinin in eight patients (seven men, mean age 53.5 years) undergoing elective percutaneous transluminal coronary angioplasty for a single left anterior descending coronary artery stenosis. Paired blood samples were obtained from the coronary sinus and the proximal aorta at baseline, immediately before balloon deflation after a 2-min inflation, and at 1, 3 and 5 min post deflation. Bradykinin levels were measured by radioimmunoassay.

RESULTS

There was no significant change either in aortic or coronary sinus bradykinin levels at any time point.

CONCLUSIONS

Intracardiac production of bradykinin is unlikely to be a trigger for ischaemic preconditioning after brief myocardial ischaemia in humans.

Beneficial effects of inhaled nitric oxide in hypoxaemic patients after coronary artery bypass surgery

OBJECTIVE

Arterial oxygenation may be impaired in the early period after open-heart surgery, with an associated increase in ventilation time, morbidity and hospital stay. We tested the hypothesis that inhaled nitric oxide could be a useful therapeutic adjunct in this setting. We sought to establish clinical benefits (if any), safety and the appropriate dose range of inhaled nitric oxide therapy in hypoxaemic patients after coronary artery bypass graft surgery.

METHODS

Forty patients who satisfied our definition of post-operative impaired oxygenation were prospectively randomised. The treatment group (n = 20) received nitric oxide in addition to ventilatory support. While the control group (n = 20) was managed only by conventional ventilatory support. Cardio-respiratory parameters and clinical outcome measures were compared.

RESULTS

We determined the optimum concentration of inhaled nitric oxide as 20 ppm in the majority (60%) of patients. Treatment improved arterial oxygenation (8.4 +/- 1.4 kPa before, 11.8 +/- 1.5 kPa after 4 h, P < 0.001) and this benefit was sustained with lower oxygen fractions required at 24 h (P < 0.001). A significantly shorter period of mechanical ventilation was required in the treatment group (mean ventilation hours 67.0 +/- 5.9 vs. 85.0 +/- 6.5, P < 0.05), although the study did not have the power to distinguish differences in ITU or overall hospital stay. Nitrous oxide and met-haemoglobin levels did not rise appreciably.

CONCLUSION

We have established the safety and efficacy of inhaled nitric oxide, at a dose of between 10 and 30 ppm, in this group of patients. We suggest that nitric oxide and a delivery system are useful adjuvants in a cardiac surgical intensive care unit.

Congenital cystic adenoid malformation in a pre-term infant: management considerations

This report describes a case of a pre-term infant with congenital cystic adenomatoid malformation involving the whole lung who received a life-saving pneumonectomy. The challenges in decision-making, surgery, and subsequent management are discussed. The principles are applicable in general to a number of babies in a paediatric intensive care unit.

"Rescue" abciximab for complicated percutaneous transluminal coronary angioplasty

We studied the in-hospital outcome of 138 consecutive patients who received abciximab as a "rescue" intervention for complicated coronary angioplasty in a high-risk clinical setting. "Rescue" treatment with abciximab was associated with clinical and angiographic success rates of 83% and 84%, respectively, whereas the risk of bleeding was higher in patients of low body weight.

Antegrade transseptal coronary angiography: an alternative technique in severe vascular disease

We report the case of a patient with severe vascular disease in whom retrograde access to the aortic root was not possible because of aortoiliac and axillary vascular disease. Antegrade coronary angiography was performed through the transseptal approach using standard catheters, although several technical difficulties were encountered.

Double-orifice right atrioventricular valve associated with partial atrioventricular septal defect

We describe the case of a double-orifice right atrioventricular valve that was discovered at operation for an associated atrioventricular septal defect. The diagnosis and operative management are discussed. Developmental concepts illustrate the mechanism by which this defect arises, and emphasize that its great rarity remains an enigma.