Fatal underhanded chronic enterovirus infection associated with anti-CD20 monotherapy for central nervous system demyelinating disease

We report a fatal case of coxsackievirus B4 chronic infection in a 30-year-old woman with a diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disorder controlled by rituximab monotherapy for 3 years. Initially presenting as self-limited meningitis, the infection remained silent for 8 months before the sudden onset of fulminant myocarditis. Analysis of the complete genome showed that the same virus was responsible for both episodes.

Risk of reoperation for aortic bioprosthesis dysfunction

BACKGROUND AND AIM OF THE STUDY

The risk of reoperative valve replacement for failed aortic bioprosthesis may be overestimated, this being a dominant factor when selecting an initial prosthesis to be implanted in patients aged <70 years. The study aims were, first, to analyze the mortality and morbidity of redo aortic bioprosthesis replacement in the current era, and second, to identify preoperative risk factors and evaluate the EuroSCORE.

METHODS

A total of 156 consecutive patients (111 men, 45 women; mean age 60.9 years; range: 23-87 years) who underwent reoperation for failed aortic bioprosthesis between 1990 and 2006 was reviewed in this retrospective, single-center study. Surgery was undertaken due to bioprosthesis degeneration (82.7%), bacterial prosthetic endocarditis (14.1%), paravalvular leak (1.3%) and other causes (1.9%). Emergency procedures were performed in 9% of patients. Associated procedures were coronary artery bypass grafting in 7.7% of patients, ascending aortic graft in 7%, and complete aortic root replacement in 6.4%. The predictive mortality was 8% according to the Additive EuroSCORE, and 15% according to the Logistic EuroSCORE.

RESULTS

Overall, the operative mortality was 3.8% (n = 6), and postoperative morbidity was low. The only multivariable predictor was emergency surgery (OR = 15.22, 95% CI = 1.68-86.43; p = 0.02). A mortality trend was associated with atrial fibrillation and NYHA class III/IV, but this was not statistically significant (p = 0.09 and p = 0.06, respectively). Associated procedures were not significant risk factors for mortality.

CONCLUSION

Reoperation for aortic bioprosthesis dysfunction can be performed with a low risk of mortality. It appears that this risk is overestimated by the EuroSCORE. Those patients who wish to avoid postoperative anticoagulant therapy may choose to receive this type of valve, even if reoperation is foreseeable.

Surgical treatment of active aortic endocarditis: homografts are not the cornerstone of outcome

BACKGROUND

Surgical treatment of active aortic infective endocarditis is challenging, and the type of prosthesis to be implanted during the active phase remains controversial.

METHODS

All consecutive patients with definite diagnosis of aortic infective endocarditis operated on during the active phase were included. Endpoints were in-hospital mortality and a combined endpoint including infective endocarditis recurrence, prostheses dysfunction, or long-term cardiovascular mortality.

RESULTS

Among 127 consecutive patients, mean age 57 +/- 15 years, 87% male, 30% with preexisting aortic prosthesis, and 63 (50%) with annulus abscess, 54 (43%) were treated with aortic homograft and 73 (57%) with conventional prosthesis. Median time between diagnosis and surgery was 10 days. In-hospital mortality was 9%, not different between homograft and conventional prostheses (11% versus 8%, p[ = 0.6). By multivariable analysis, prosthetic valve endocarditis (8.5 95% confidence interval: 2.2 to 33.6, ]p = 0.001) was the only variable independently associated with in-hospital mortality, which was not influenced by type valvular substitute (p = 0.6), even in the subset with annulus abscess (p = 0.2). Ten-year survival free from the combined endpoint was 44% +/- 10%, not different between homograft and conventional prostheses (log rank p = 0.2). By multivariable analysis, comorbidity index (2.6 [1.05 to 6.3], p = 0.04) and prosthetic valve endocarditis (2.3 [1.2 to 4.6], p = 0.02) were independently predictive of the combined endpoint, which was not determined by type of valvular substitute (p = 0.6) even in the subset with annulus abscess (p = 0.5).

CONCLUSIONS

Implantation of conventional prostheses during the active phase of aortic endocarditis yields similar low operative mortality and long-term prognosis as compared with aortic homografts, even in patients with annulus abscess.

Eclipsed mitral regurgitation: a new form of functional mitral regurgitation for an unusual cause of heart failure with normal ejection fraction

BACKGROUND

Transient functional mitral regurgitation (MR) has never been reported as a cause of heart failure (HF) with normal ejection fraction (EF) in the absence of epicardial coronary artery stenosis.

RESULTS

Performance of echocardiography in patients with acute HF before initiation of HF medical treatment allowed identification of three patients with normal EF but transient massive functional MR during the HF episode. In all patients, massive MR occurred as a consequence of sudden extreme apical tenting of both leaflets with total lack of coaptation, despite normal EF and absence of detectable left ventricular (LV) remodeling, and despite absence of significant stenosis on coronary arteries. In all patients MR was triggered by methylergonovine injection and was reversible either spontaneously or after nitroglycerine administration, leaving patients with normal echocardiogram between HF episodes. In two patients, long-term administration of calcium channel blockers prevented recurrences of MR and HF, whereas in one, mitral valve was eventually replaced.

CONCLUSION

Sudden reversible apical tenting of mitral leaflets with subsequent torrential MR and acute HF can occur despite normal EF, absence of pre-existing LV remodeling and absence of coronary artery stenosis. This atypical type of functional MR is an unusual mechanism of HF in patients with normal LVEF.

Rapid ventricular pacing induces delayed cardioprotection against myocardial stunning

Tachycardia with rapid ventricular pacing induces delayed preconditioning against arrhythmias secondary to coronary artery occlusion (CAO) and reperfusion (CAR) but its effects on myocardial stunning remains unknown. Accordingly, we investigated whether delayed preconditioning with ventricular pacing develops against myocardial stunning and whether this phenomenon is triggered by reactive oxygen species. Eight chronically instrumented conscious dogs underwent three experimental sequences in a random order a week apart: (a) 10-min CAO (coronary occluder) followed by CAR, i.e. "Control" sequence; (b) pacing (right ventricular electrodes, 240 beats/min during 40 min) performed 24 h before the 10-min CAO, i.e. "PC" sequence; and (c) N-(2-mercaptopropionyl)-glycine (MPG, 100 mg/kg per h) administered concomitantly to pacing and 10-min CAO performed 24 h later, i.e. "PC+MPG" sequence. During "Control", left ventricular (LV) wall thickening (%, sonomicrometry) was dramatically reduced during CAO (-96 +/- 5% from 2.9 +/- 0.4 mm) and remained depressed during CAR demonstrating myocardial stunning. During "PC", LV wall thickening was not altered by pacing per se and was similarly decreased during CAO vs. "Control". However, during CAR, LV wall thickening was improved vs. "Control" (e.g. -24 +/- 5% and -8 +/- 4% from corresponding baseline for "PC" and "Control", respectively at 2 h-CAR; P<0.05), demonstrating delayed preconditioning. Administration of MPG during pacing (n=5) abolished the beneficial effects of pacing. Myocardial lactate extraction and transmural distribution of regional myocardial blood flow (fluorescent microspheres) were not modified, by pacing. In conclusion, tachycardia with rapid ventricular pacing induces delayed cardioprotection against myocardial stunning. The production of reactive oxygen species independently from ischemia appears to be a major trigger for this phenomenon.

Transdiaphragmatic hernia 1 year after heart transplantation following implantable LVAD

Complications after ventricular assist devices placement most frequently consist of bleeding, infection, and thromboembolic events. We describe a late complication after transplantation caused by transdiaphragmatic connection of the device placed in the abdominal position that presented as an acute pulmonary syndrome, misleading initial diagnosis.