Surgery in patients with infective endocarditis and prognostic importance of patient frailty

PURPOSE

Surgery is required in 20-50% of patients with infective endocarditis (IE). Frailty increases surgical risk; however, the prognostic implications of frailty in patients undergoing IE-related surgery remain poorly understood. We aimed to assess the association between frailty and all-cause mortality or rehospitalization after discharge (≥ 14 days).

METHODS

We identified all IE patients who underwent surgery during admission (2010-2020) in Denmark. The Hospital Frailty Risk Score was used to categorize patients into two frailty risk groups, patients with low frailty scores (< 5 points) and frail patients (≥ 5 points). We analyzed time hospitalized after discharge and all-cause mortality from the date of surgery with a one-year follow-up. Statistical analyses utilized the Kaplan-Meier estimator, Aalen-Johansen estimator, and the Cox regression model.

RESULTS

We identified 1282 patients who underwent surgery during admission, of whom 967 (75.4%) had low frailty scores, and 315 (24.6%) were frail. Frail patients were characterized by advanced age, a lower proportion of males, and a higher burden of comorbidities. Frail patients were more hospitalized (> 14 days) in the first post-discharge year (19.1% vs.12.3%) compared to patients with low frailty scores. Additionally, frail patients had higher rates of all-cause mortality including in-hospital deaths (27% vs. 15%) and rehospitalizations (43.5% vs 26.1%) compared to patients with low frailty scores. This was also evident in the adjusted analysis (hazard ratio 1.36 [CI 95% 1.09-1.71]).

CONCLUSION

Frailty was associated with an ≈40% increased rate of rehospitalization (≥ 14 days) or death. Further studies are needed to assess the effectiveness of surgery with a focus on frailty to improve prognostic outcomes in these patients.

Pulmonary Valve Replacement in Tetralogy of Fallot: Procedural Volume and Durability of Bioprosthetic Pulmonary Valves

BACKGROUND

Robust data on changes in pulmonary valve replacement (PVR) procedural volume and predictors of bioprosthetic pulmonary valve (BPV) durability in patients with tetralogy of Fallot (TOF) are scarce.

OBJECTIVES

This study sought to assess temporal trends in PVR procedural volume and BPV durability in a nationwide, retrospective TOF cohort.

METHODS

Data were obtained from patient records. Robust linear regression was used to assess temporal trends in PVR procedural volume. Piecewise exponential additive mixed models were used to estimate BPV durability, defined as the time from implantation to redo PVR with death as a competing risk, and to assess risk factors for reduced durability.

RESULTS

In total, 546 PVR were performed in 384 patients from 1976 to 2021. The annual number of PVR increased from 0.4 to 6.0 per million population (P < 0.001). In the last decade, the transcatheter PVR volume increased by 20% annually (P < 0.001), whereas the surgical PVR volume did not change significantly. The median BPV durability was 17 years (Q1: 10-Q3: 10 years-not applicable). There was no significant difference in the durability of different BPV after adjustment for confounders. Age at PVR (HR: 0.78 per 10 years from <1 year; 95% CI: 0.63-0.96; P = 0.02) and true inner valve diameter (9-17 mm vs 18-22 mm HR: 0.40; 95% CI: 0.22-0.73; P = 0.003 and 18-22 mm vs 23-30 mm HR: 0.59; 95% CI: 0.25-1.39; P = 0.23) were associated with reduced BPV durability in multivariate models.

CONCLUSIONS

The PVR procedural volume has increased over time, with a greater increment in transcatheter than surgical PVR during the last decade. Younger patient age at PVR and a smaller true inner valve diameter predicted reduced BPV durability.

Fresh and frozen cardiac tissue are comparable in DNA methylation array β-values, but formalin-fixed, paraffin-embedded tissue may overestimate DNA methylation levels

Untreated fresh cardiac tissue is the optimal tissue material for investigating DNA methylation patterns of cardiac biology and diseases. However, fresh tissue is difficult to obtain. Therefore, tissue stored as frozen or formalin-fixed, paraffin-embedded (FFPE) is widely used for DNA methylation studies. It is unknown whether storage conditions alter the DNA methylation in cardiac tissue. In this study, we compared the DNA methylation patterns of fresh, frozen, and FFPE cardiac tissue to investigate if the storage method affected the DNA methylation results. We used the Infinium MethylationEPIC assay to obtain genome-wide methylation levels in fresh, frozen, and FFPE tissues from nine individuals. We found that the DNA methylation levels of 21.4% of the examined CpG sites were overestimated in the FFPE samples compared to that of fresh and frozen tissue, whereas 5.7% were underestimated. Duplicate analyses of the DNA methylation patterns showed high reproducibility (precision) for frozen and FFPE tissues. In conclusion, we found that frozen and FFPE tissues gave reproducible DNA methylation results and that frozen and fresh tissues gave similar results.

Microbiological Etiology in Patients with IE Undergoing Surgery and for Patients with Medical Treatment Only: A Nationwide Study from 2010 to 2020

Microbiological etiology has been associated with surgery for infective endocarditis (IE) during admission, especially Staphylococcus aureus. We aimed to compare patient characteristics, microbiological characteristics, and outcomes by treatment choice (surgery or not). We identified patients with first-time IE between 2010 and 2020 and examined the microbiological etiology of IE according to treatment choice. To identify factors associated with surgery during initial admission, we used the Aalen-Johansen estimator and an adjusted cause-specific Cox model. One-year mortality stratified by microbiological etiology and treatment choice was assessed using unadjusted Kaplan-Meier estimates and an adjusted Cox proportional hazard model. A total of 6255 patients were included, of which 1276 (20.4%) underwent surgery during admission. Patients who underwent surgery were younger (65 vs. 74 years) and less frequently had cerebrovascular disease, cardiovascular disease, diabetes, and chronic kidney disease. Patients with Staphylococcus aureus IE were less likely to undergo surgery during admission (13.6%) compared to all other microbiological etiologies. One-year mortality according to microbiological etiology in patients who underwent surgery was 7.0%, 5.3%, 5.5%, 9.6%, 13.2, and 11.2% compared with 24.2%, 19.1%, 27,6%, 25.2%, 21%, and 16.9% in patients who received medical therapy for Staphylococcus aureus, Streptococcus spp., Enterococcus spp., coagulase-negative Staphylococci, "other microbiological etiologies", and blood culture-negative infective endocarditis, respectively. Patients with IE who underwent surgery differed in terms of microbiology, more often having Streptococci than those who received medical therapy. Contrary to expectations, Staphylococcus aureus was more common among patients who received medical therapy only.

Postoperative free water administration is associated with dysnatremia after congenital heart disease surgery in infants

Dysnatremia after congenital heart disease (CHD) surgery is common. European guidelines on intraoperative fluid therapy in children recommend isotonic solutions to avoid hyponatremia, but prolonged cardiopulmonary bypass and administration of high sodium-containing solutions (i.e., blood products and sodium bicarbonate) are associated with postoperative hypernatremia. The aim of the study was to describe fluid composition prior to and during the development of postoperative dysnatremia. A retrospective observational, single-center study including infants undergoing CHD surgery. Demographics and clinical characteristics were registered. Highest and lowest plasma sodium values were recorded and associations with perioperative fluid administration, blood products, crystalloids, and colloids were explored in relation to three perioperative periods. Postoperative dysnatremia occurred in nearly 50% of infants within 48 h after surgery. Hypernatremia was mainly associated with administration of blood products (median [IQR]: 50.5 [28.4-95.5] vs. 34.5 [18.5-61.1] mL/kg; p = 0.001), and lower free water load (1.6 [1.1-2.2] mL/kg/h; p = 0.01). Hyponatremia was associated with a higher free water load (2.3 [1.7-3.3] vs. 1.8 [1.4-2.5] mL/kg/h; p = 0.001) and positive fluid balance. On postoperative day 1, hyponatremia was associated with higher volumes of free water (2.0 [1.5-2.8] vs. 1.3 [1.1-1.8] mL/kg/h; p < 0.001) and human albumin, despite a larger diuresis and more negative daily fluid balance. Postoperative hyponatremia occurred in 30% of infants despite restrictive volumes of hypotonic maintenance fluid, whereas hypernatremia was mainly associated with blood product transfusion. Individualized fluid therapy, with continuous reassessment to reduce the occurrence of postoperative dysnatremia is mandatory in pediatric cardiac surgery. Prospective studies to evaluate fluid therapy in pediatric cardiac surgery patients are warranted.

Temporal changes in the surgical management of patients with tetralogy of Fallot in Denmark: a nationwide cohort study

OBJECTIVES

To assess temporal changes in the surgical management of patients with tetralogy of Fallot including the timing of interventions, surgical techniques, reinterventions and survival in a nationwide cohort.

METHODS

Patients with tetralogy of Fallot in Denmark were divided into 3 eras based on their year of birth: early (1977-1991), intermediate (1992-2006) and late (2007-2021).

RESULTS

The cohort consisted of 745 patients. Median follow-up was 21.2 years (13.7-30.5). There was a temporal trend towards less shunt palliation (-0.3% per year, 95% CI -0.05 to -0.1). Median age at intracardiac repair was 2.9 years (1.8-5.0), 0.8 years (0.5-1.3) and 0.5 years (0.4-0.7) (P < 0.001) in the early, intermediate and late era, respectively. There was a temporal trend towards less valve-sparing repair (-0.7% per year, 95% CI -0.5 to -1.0) and more repair with transannular patches (0.7% per year, 95% CI 0.5-1.0). Survival at 10 years was 79% (64-76), 90% (87-93) and 95% (92-98) (P < 0.001) and pulmonary valve replacement within the first 10 years after intracardiac repair was performed in 3% (1-6), 12% (8-16) and 21% (13-29) (P < 0.001) in the early, intermediate and late era, respectively.

CONCLUSIONS

There was a temporal trend towards less shunt palliation and intracardiac repair at a younger age with more use of transannular patches. While survival throughout childhood and adolescence has improved, more patients undergo pulmonary valve replacement during the first 10 years after intracardiac repair.

Comparison of whole transcriptome sequencing of fresh, frozen, and formalin-fixed, paraffin-embedded cardiac tissue

The use of fresh tissue for molecular studies is preferred but often impossible. Instead, frozen or formalin-fixed, paraffin-embedded (FFPE) tissues are widely used and constitute valuable resources for retrospective studies. We assessed the utility of cardiac tissue stored in different ways for gene expression analyses by whole transcriptome sequencing of paired fresh, frozen, and FFPE tissues. RNA extracted from FFPE was highly degraded. Sequencing of RNA from FFPE tissues yielded higher proportions of intronic and intergenic reads compared to RNA from fresh and frozen tissues. The global gene expression profiles varied with the storage conditions, particularly mitochondrial and long non-coding RNAs. However, we observed high correlations among protein-coding transcripts (ρ > 0.94) with the various storage conditions. We did not observe any significant storage effect on the allele-specific gene expression. However, FFPE had statistically significantly (p < 0.05) more discordant variant calls compared to fresh and frozen tissue. In conclusion, we found that frozen and FFPE tissues can be used for reliable gene expression analyses, provided that proper quality control is performed and caution regarding the technical variability is withheld.

Temporal trends in the incidence of endocarditis among patients with a prosthetic heart valve: a nationwide study

Background

The incidence of infective endocarditis (IE) is increasing in the adult population, as is the insertion of prosthetic heart valves. Patients with prosthetic heart valves are considered at high risk of IE – a complication with a high mortality. However, data on temporal changes in the incidence of IE among patients with prosthetic heart valves from unselected cohorts are sparse

Purpose

We aimed to examine nationwide temporal trends in the incidence of IE in patients with an implanted prosthetic heart valve in Denmark from 1999 to 2018.

Methods

Using Danish nationwide health-care registries we identified all patients, who underwent heart valve implantation between 1996–2018. Crude annual incidence rates per 1,000 person years (PY) of IE were computed and presented in two year intervals. Analyses were stratified by sex and age groups (&lt;50, 50–59, 60–69, 70–79, &gt;80 years).

Results

We identified 26,604 patients with first time prosthetic valve implantation with a median age of 72.7 years at the time of implantation, 63.1% were men with a median follow-up of 6.5 years. We found 1,442 cases of first time IE. The IE incidence rate ranged from 5.4 /1,000 PY (95% CI 3.9–7.4) in calendar period 2001–2002 to 10.0/1,000 PY (95% 8.84–11.11) in calendar period 2017–2018 with an unadjusted increasing trend during the study period (ptrend&lt;0.0001), (Figure 1). Overall, men had a higher crude incidence rate compared with women, however no significant temporal changes were seen in the incidence rate during the study period. For age groups, a trend of stepwise increase in the incidence rate of IE was observed for increasing age groups, however no temporal changes were observed (Figure 2).

Conclusion

The incidence of IE following prosthetic heart valve implantation has increased slightly over the last 20 years in Denmark.

Funding Acknowledgement

Type of funding sources: None.

Postoperative dysnatremia in infants after open-heart surgery occurs frequently and is associated with prolonged intensive care length of stay

BACKGROUND

Dysnatremia after surgery for congenital heart disease (CHD) is well known and has been associated with prolonged pediatric intensive care unit length of stay (PICU-LOS). Fluctuations in plasma sodium levels occur perioperatively. The primary aim of the study was to evaluate the occurrence of dysnatremia during the first 48 h after surgery and whether it was associated with PICU-LOS. The secondary aim was to evaluate if the degree of sodium fluctuations was associated with PICU-LOS.

METHODS

A retrospective observational, single-center study including infants undergoing surgery for CHD. The highest and lowest plasma sodium value was registered for the prespecified time periods. PICU-LOS was analyzed in relation to the occurrence of dysnatremia and the degree of plasma sodium fluctuations. The occurrence of dysnatremia was evaluated in relation to surgical procedure and fluid administration.

RESULTS

Two hundred and thirty infants who underwent 249 surgical procedures were included. Dysnatremia developed in more than 60% within 48 h after surgery. Infants with normonatremia had a 40%-50% shorter PICU-LOS among children in RACHS-1 category 3-6, compared with infants developing either hypo- or hyper-/hyponatremia within 48 h after surgery (p = .006). Infants who had a decline of plasma sodium >11 mmol/L had almost double the PICU-LOS compared to those with a decline of <8 mmol/L.

CONCLUSION

Dysnatremias were common after surgery for CHD and associated with prolonged PICU-LOS. The degree of decline in plasma sodium was significantly associated with PICU-LOS. Fluid administration both in terms of volume and components (blood products and crystalloids) as well as diuresis were related to the occurrence of dysnatremias.

Differences in mortality in patients undergoing surgery for infective endocarditis according to age and valvular surgery

Background

Infective endocarditis (IE) is associated with high mortality. Surgery may improve survival and reduce complications, but the balance between benefit and harm is difficult and may be closely related to age and type of surgical intervention. We aimed to examine how age and type of left-sided surgical intervention modified mortality in patients undergoing surgery for IE.

Methods

By crosslinking nationwide Danish registries we identified patients with first-time IE undergoing surgical treatment 2000–2017. Patients were grouped by age < 60 years, 60–75 years, and ≥ 75 years. Multivariable adjusted Cox proportional hazard analysis was used to examine factors associated with 90-day mortality.

Results

We included 1767 patients with IE undergoing surgery, 735 patients < 60 years (24.1% female), 766 patients 60–75 years (25.8% female), and 266 patients ≥75 years (36.1% female). The proportions of patients undergoing surgery were 35.3, 26.9, and 9.1% for patients < 60 years, 60–75 years, and > 75 years, respectively. Mortality at 90 days were 7.5, 13.9, and 22.3% (p < 0.001) for three age groups. In adjusted analyses, patients 60–75 years and patients ≥75 years were associated with a higher mortality, HR = 1.84 (95% CI: 1.48–2.29) and HR = 2.47 (95% CI: 1.88–3.24) as compared with patients < 60 years. Factors associated with 90-day mortality were: mitral valve surgery, a combination of mitral and aortic valve surgery as compared with isolated aortic valve surgery, age, diabetes, and prosthetic heart valve implantation prior to IE admission.

Conclusions

In patients undergoing surgery for IE, mortality increased significantly with age and 1 in 5 died above age 75 years. Mitral valve surgery as well as multiple valve interventions augmented mortality further.

Incidence and factors associated with infective endocarditis in patients undergoing left-sided heart valve replacement

Aims

Patients with left-sided heart valve replacement are considered at high-risk of infective endocarditis (IE). However, data on the incidence and risk factors associated with IE are sparse.

Methods and results

Through Danish administrative registries, we identified patients who underwent left-sided heart valve replacement from January 1996 to December 2015. Patients were categorized in mitral and aortic valve replacement (MVR and AVR) and followed until: 12 years after valve surgery, end of study, death, emigration, or hospitalization due to IE, whichever came first. Multivariable adjusted Cox proportional hazard analysis was used to investigate which baseline characteristics were associated with IE. A total of 18 041 patients were included. The cumulative IE risk at 10 years follow-up was 5.2% in both MVR and AVR patients. In patients with MVR, male sex [hazard ratio (HR) = 1.68, 95% confidence interval (95% CI) 1.06-2.68], bioprosthetic valve (HR = 1.91, 95% CI 1.08-3.37), and heart failure (HR = 1.69, 95% CI 1.06-2.68) were among factors associated with an increased risk of IE. In AVR patients, male sex (HR = 1.59, 95% CI 1.33-1.89), bioprosthetic valve (HR = 1.70, 95% CI 1.35-2.15), and cardiac implantable electronic device (CIED) (HR = 1.57, 95% CI 1.19-2.06) were among factors associated with an increased risk of IE.

Conclusion

Infective endocarditis after left-sided heart valve replacement is not uncommon and occurs in about 1/20 over 10 years. Male, bioprosthetic valve, and heart failure were among factors associated with IE in MVR patients while male, bioprosthetic valve, and CIED were among factors associated with IE in AVR patients.

Severe traumatic tricuspid valvular insufficiency detected 28 years after blunt chest trauma - A case report

INTRODUCTION

Tricuspid valvular insufficiency is a rare complication following blunt chest trauma. The prevalence of the condition may be underestimated due to subtle clinical symptoms.

PRESENTATION OF CASE

We report a case of tricuspid valvular insufficiency in a 44-year-old man detected 28 years after a high-energy moped-accident. Surgery was required, consisting of leaflet resuspension with an artificial chorda and a ring annuloplasty.

DISCUSSION

Tricuspid valvular insufficiency secondary to blunt chest trauma is sometimes first detected several years after the index event due to few symptoms. This may lead to a delay in treatment, and thus result in irreversible dilatation of the right-sided cavities.

CONCLUSION

Valve repair is preferable to valve replacement, since patients are typically young and active. Better surgical results and avoidance of late complications can be obtained if the patient is operated when still asymptomatic.

Serotonin markers show altered transcription levels in an experimental pig model of mitral regurgitation

Serotonin (5-hydroxytryptamine, 5-HT) signalling is implicated in the pathogenesis of myxomatous mitral valve disease (MMVD) through 5-HT1B receptor (R), 5-HT2AR and 5-HT2BR-induced myxomatous pathology. Based on increased tryptophan hydroxylase-1 (TPH-1) and decreased serotonin re-uptake transporter (SERT) in MMVD-affected valves, increased valvular 5-HT synthesis and decreased clearance have been suggested. It remains unknown how haemodynamic changes associated with mitral regurgitation (MR) affect 5-HT markers in the mitral valve, myocardium and circulation. Twenty-eight pigs underwent surgically induced MR or sham-operation, resulting in three MR groups: control (CON, n = 12), mild MR (mMR, n = 10) and severe MR (sMR, n = 6). The gene expression levels of 5-HT1BR, 5-HT2AR, 5-HT2BR, SERT and TPH-1 were analysed using quantitative PCR (qPCR) in the mitral valve (MV), anterior papillary muscle (AP) and left ventricle (LV). MV 5-HT2BR was also analysed with immunohistochemistry (IHC) in relation to histological lesions and valvular myofibroblasts. All 5-HTR mRNAs were up-regulated in MV compared to AP and LV (P <0.01). In contrast, SERT and TPH-1 were up-regulated in AP and LV compared to MV (P <0.05). In MV, mRNA levels were increased for 5-HT2BR (P = 0.02) and decreased for SERT (P = 0.03) in sMR vs. CON. There were no group differences in 5-HT2BR staining (IHC) but co-localisation was found with α-SMA-positive cells in 91% of all valves and with 33% of histological lesions. In LV, 5-HT1BR mRNA levels were increased in sMR vs. CON (P = 0.01). In conclusion, these data suggest that MR may affect mRNA expression of valvular 5-HT2BR and SERT, and left ventricular 5-HT1BR in some pigs.

Which exercise test to use for chest pain from an anomalous coronary artery

Chest pain in children and young people is a frequent cause of contact to general practitioners and outpatient clinics. However, in children, chest pain is typically benign and self-limiting; it is not usually a manifestation of organic disease, and it is very rarely of cardiac origin. The cause of chest pain often remains undiagnosed. There are a number of chronic conditions known to be associated with recurrent chest pain. Symptoms and signs include crushing left-sided precordial pain, pain radiating to the left arm or the jaw, pain onset with exercise and subsiding at rest (with asthma excluded), and an abnormal cardiovascular examination suggests referral for cardiac evaluation. We here report a case of stable angina pectoris in the young.