Purpose of the Review
Infective endocarditis (IE) is a relatively infrequent infectious disease. It does, however, causes serious morbidity, and its mortality rate has remained unchanged at ...approximately 25%. Changes in IE risk factors have deeply impacted its epidemiology during recent decades but literature from low-income countries is very scarce. Moreover, prophylaxis guidelines have recently changed and the impact on IE incidence is still unknown.
Recent Findings
In high-income countries, the proportion of IE related to prior rheumatic disease has decreased significantly and has been replaced proportionally by cases related to degenerative valvulopathies, prosthetic valves, and cardiovascular implantable electronic devices. Nosocomial and non-nosocomial-acquired cases have risen, as has the proportion caused by staphylococci, and the median age of patients. In low-income countries, in contrast, rheumatic disease remains the main risk factor, and streptococci the most frequent causative agents. Studies performed to evaluate impact of guidelines changes’ have shown contradictory results.
Summary
The increased complexity of cases in high-income countries has led to the creation of IE teams, involving several specialties. New imaging and microbiological techniques may increase sensitivity for diagnosis and detection of IE cases. In low-income countries, IE remained related to classic risk factors. The consequences of prophylaxis guidelines changes are still undetermined.
Intravenous thrombolysis is contraindicated in acute ischemic stroke secondary to infective endocarditis. We report our initial experience in 6 cases of proximal vessel occlusion treated with ...mechanical thrombectomy, which was safe (no bleeding) and effective (significant early neurological improvement) and might be useful in this clinical setting.
Background
Micra transcatheter pacemaker system (TPS) usually achieves low implant pacing threshold (IPT). However, IPT may increase in some patients during follow‐up.
Aim
To apply implant parameters ...in predicting long‐term occurrence of very high pacing threshold (VHPT) in patients with Micra‐TPS.
Methods
A cohort of 110 consecutive patients implanted with a Micra‐TPS from 2014 to 2018 was evaluated at discharge and at 1, 12, 24, 36, and 48 months follow‐up. VHPT was defined as greater than 2 V/0.24 ms. VHPT predictors were identified.
Results
Micra‐TPS was implanted successfully in 108 patients (98.2%). During a mean follow‐up of 24 ± 16 months, 18 patients (16.7%) died of causes nonpacemaker‐related, and 4 (3.8%) developed VHPT. Patients with VHPT had higher IPT and lower implant impedance than patients with non‐VHPT: 1 ± 0.31 vs 0.55 ± 0.29 V/0.24 ms (P = .003) and 580 ± 59 vs 837 ± 232 Ω (P = .03), respectively. IPT and impedance had excellent discriminative power to predict VHPT (area under the curve: 0.85 ± 0.07 and 0.91 ± 0.05, respectively). Negative predictive value (NPV) of IPT ≤ 0.5 V/0.24 ms was 100%; positive predictive value (PPV) was 8% throughout follow‐up. Implant impedance ≤ 600 Ω had NPV of 99% throughout follow‐up, whereas PPV varied: 16%, 21%, 16%, and 28% at 1, 12, 24, and 36 months, respectively. Sequential combination of IPT greater than 0.5 V/0.24 ms and impedance ≤ 600 Ω improved PPV to 25%, 35%, 27%, and 44%, respectively, whereas NPV remained 99% throughout follow‐up.
Conclusion
Despite favorable long‐term electrical performance of Micra‐TPS, a small percent of patients developed VHPT during follow‐up. A sequential combination of IPT and impedance could allow the implanter to identify patients who will develop VHPT during long‐term follow‐up.
The study aimed to describe the epidemiological, microbiological, and clinical features of a population sample of 17 patients with HACEK infective endocarditis (HACEK-IE) and to compare them with ...matched control patients with IE caused by viridans group streptococci (VGS-IE).
Cases of definite (n=14, 82.2%) and possible (n=3, 17.6%) HACEK-IE included in the Infective Endocarditis Hospital Clinic of Barcelona (IE-HCB) database between 1979 and 2016 were identified and described. Furthermore, a retrospective case–control analysis was performed, matching each case to three control subjects with VGS-IE registered in the same database during the same time period.
Seventeen out of 1209 IE cases (1.3%, 95% confidence interval 0.69–1.91%) were due to HACEK group organisms. The most frequently isolated HACEK species were Aggregatibacter spp (n=11, 64.7%). Intracardiac vegetations were present in 70.6% of cases. Left heart failure (LHF) was present in 29.4% of cases. Ten patients (58.8%) required in-hospital surgery and none died during hospitalization. In the case–control analysis, there was a trend towards larger vegetations in the HACEK-IE group (median (interquartile range) size 11.5 (10.0–20.0) mm vs. 9.0 (7.0–13.0) mm; p=0.068). Clinical manifestations, echocardiographic findings, LHF rate, systemic emboli, and other complications were all comparable (p>0.05). In-hospital surgery and mortality were similar in the two groups. One-year mortality was lower for HACEK-IE (1/17 vs. to 6/48; p=0.006).
HACEK-IE represented 1.3% of all IE cases. Clinical features and outcomes were comparable to those of the VGS-IE control group. Despite the trend towards a larger vegetation size, the embolic event rate was not higher and the 1-year mortality was significantly lower for HACEK-IE.
Early performance of the Micra transcatheter pacemaker from the global clinical trial reported a 99.2% implant success rate, low and stable pacing capture thresholds, and a low (4.0%) rate of major ...complications up to 6 months.
The purpose of this report was to describe the prespecified long-term safety objective of Micra at 12 months and electrical performance through 24 months.
The Micra Transcatheter Pacing Study was a prospective single-arm study designed to assess the safety and efficacy of the Micra VVIR leadless/intracardiac pacemaker. Enrolled patients met class I or II guideline recommendations for de novo ventricular pacing. The long-term safety objective was freedom from a system- or procedure-related major complication at 12 months. A predefined historical control group of 2667 patients with transvenous pacemakers was used to compare major complication rates.
The long-term safety objective was achieved with a freedom from major complication rate of 96.0% at 12 months (95% confidence interval 94.2%–97.2%; P < .0001 vs performance goal). The risk of major complications for patients with Micra (N = 726) was 48% lower than that for patients with transvenous systems through 12 months postimplant (hazard ratio 0.52; 95% confidence interval 0.35–0.77; P = .001). Across subgroups of age, sex, and comorbidities, Micra reduced the risk of major complications compared to transvenous systems. Electrical performance was excellent through 24 months, with a projected battery longevity of 12.1 years.
Long-term performance of the Micra transcatheter pacemaker remains consistent with previously reported data. Few patients experienced major complications through 12 months of follow-up, and all patient subgroups benefited as compared to transvenous pacemaker historical control group.
and
species are fastidious organisms, representing the causative agents of ∼1% to 3% of cases of infective endocarditis (IE). Little is known about the optimal antibiotic treatment for these species, ...and daptomycin has been suggested as a therapeutic option. We describe the antimicrobial profiles of
and
IE isolates, investigate high-level daptomycin resistance (HLDR) development, and evaluate daptomycin activity in combination therapy.
studies with 16 IE strains (6 Abiotrophia defectiva strains, 9 Granulicatella adiacens strains, and 1 G. elegans strain) were performed using microdilution to determine MICs and time-kill methodology to evaluate combination therapy. Daptomycin nonsusceptibility (DNS) (MIC ≥ 2 mg/liter) and HLDR (MIC ≥ 256 mg/liter) were based on existing Clinical and Laboratory Standards Institute (CLSI) breakpoints for viridans group streptococci. All isolates were susceptible to vancomycin: G. adiacens was more susceptible to penicillin and ampicillin than A. defectiva (22% versus 0% and 67% versus 33%) but less susceptible to ceftriaxone and daptomycin (56% versus 83% and 11% versus 50%). HLDR developed in both A. defectiva (33%) and
(78%) after 24 h of exposure to daptomycin. Combination therapy did not prevent the development of daptomycin resistance with ampicillin (2/3 strains), gentamicin (2/3 strains), ceftriaxone (2/3 strains), or ceftaroline (2/3 strains). Once developed, HLDR was stable for a prolonged time (>3 weeks) in
, whereas in A. defectiva, HLDR reversed to the baseline MIC at day 10. This study is the first to demonstrate rapid HLDR development in
and
species
. Resistance was stable, and most combination therapies did not prevent it.
Abstract
Background
Studies investigating cardiac implantable electronic device infective endocarditis (CIED-IE) epidemiological changes and prognosis over long periods of time are lacking.
Methods
...Retrospective single cardiovascular surgery center cohort study of definite CIED-IE episodes between 1981–2020. A comparative analysis of two periods (1981–2000 vs 2001–2020) was conducted to analyze changes in epidemiology and outcome over time.
Results
One-hundred and thirty-eight CIED-IE episodes were diagnosed: 25 (18%) first period and 113 (82%) second. CIED-IE was 4.5 times more frequent in the second period, especially in implantable cardiac defibrillators. Age (63 53-70 vs 71 63–76 years, P < .01), comorbidities (CCI 3.0 2–4 vs 4.5 3–6, P > .01), nosocomial infections (4% vs 15.9%, P = .02) and transfers from other centers (8% vs 41.6%, P < .01) were significantly more frequent in the second period, as were methicillin-resistant coagulase-negative staphylococcal (MR-CoNS) (0% vs 13.3%, P < .01) and Enterococcus spp. (0% vs 5.3%, P = .01) infections, pulmonary embolism (0% vs 10.6%, P < .01) and heart failure (12% vs 28.3%, p < .01). Second period surgery rates were lower (96% vs 87.6%, P = .09), and there were no differences in in-hospital (20% vs 11.5%, P = .11) and one-year mortalities (24% vs 15%, P = .33), or relapses (8% vs 5.3%, P = 0.65). Multivariate analysis showed Charlson index (hazard ratios 95% confidence intervals; 1.5 1.16–1.94) and septic shock (23.09 4.57–116.67) were associated with a worse prognosis, whereas device removal (0.11 .02–.57), transfers (0.13 .02–0.95), and second-period diagnosis (0.13 .02–.71) were associated with better one-year outcomes.
Conclusions
CIED-IE episodes increased more than four-fold during last 40 years. Despite CIED-IE involved an older population with more comorbidities, antibiotic-resistant MR-CoNS, and complex devices, one-year survival improved.
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current ...knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
Identification of local abnormal electrograms (EGMs) during ventricular tachycardia substrate ablation (VTSA) is challenging when they are hidden within the far-field signal. This study analyses ...whether the response to a double ventricular extrastimulus during substrate mapping could identify slow conducting areas that are hidden during sinus rhythm.
Consecutive patients (n = 37) undergoing VTSA were prospectively included. Bipolar EGMs with >3 deflections and duration <133 ms were considered as potential hidden slow conduction EGMs (HSC-EGM) if located within/surrounding the scar area. Whenever a potential HSC-EGM was identified, a double ventricular extrastimulus was delivered. If the local potential delayed, it was annotated as HSC-EGM. The incidence of HSC-EGM in core, border-zone, and normal-voltage regions was determined. Ablation was delivered at conducting channel entrances and HSC-EGMs. VT inducibility after VTSA obtained was compared with data from a historic control group. 2417 EGMs were analyzed. 575 (23.7%) qualified as potential HSC-EGM, and 198 of them were tagged as HSC-EGMs. Scars in patients with HSC-EGMs (n = 21, 56.7%) were smaller (35.424.7 vs 67.639.1 cm2; P = 0.006) and more heterogeneous (core/scar area ratio 0.250.2 vs 0.450.19; P = 0.02). 28.8% of HSC-EGMs were located in normal-voltage tissue; 81.3% were targeted for ablation. Patients undergoing VTSA incorporating HSC analysis needed less radiofrequency time (17.411 vs 2310.7 minutes; P = 0.016) and had a lower rate of VT inducibility after VTSA than the historic controls (24.3% vs 50%; P = 0.018).
Ventricular tachycardia substrate ablation incorporating HSC analysis allowed further arrhythmic substrate identification (especially in normal-voltage areas) and reduced RF time and VT inducibility after VTSA.
Aims
The beneficial effects of CRT in patients with advanced heart failure, wide QRS, and low LVEF have been clearly established. Nevertheless, mortality remains high in some patients. The aims of ...our study were to identify the predictors of mortality in patients treated with CRT and to design a risk score for mortality.
Methods and results
A cohort of 608 consecutive patients treated with CRT from 2000 to 2011 in our centre was prospectively analysed. Baseline clinical and echocardiography variables were analysed and mortality data were collected. During a mean follow‐up of 36.2 ± 29.2 months, 174 patients died: 123/174 (71%) due to cardiovascular causes, 25/174 (14%) non‐cardiac causes, and 26/174 (15%) unknown aetiology. In a multivariate analysis the predictors of mortality were NYHA class IV hazard ratio (HR) 2.54, 95% confidence interval (CI) 1.7–3.7, P < 0.001, glomerular filtration rate (GFR) <60 mL/min/1.73 m2 (HR 1.61, 95% CI 1.14–2.30, P = 0.008), AF (HR 1.67, 95% CI 1.19–2.3, P = 0.01), age ≥70 years (HR 1.44, (95% CI 1.04–2.00, P = 0.02), and LVEF <22% (HR 1.83, 95% CI 1.33–2.52, P ≤ 0.001). The EAARN score (EF, Age, AF, Renal dysfunction, NYHA class IV) summarizes the predictors. Each additional predictor increased the mortality: one predictor, HR 3.28 (95% CI 1.37–7.8, P = 0.008); two, HR 5.23 (95% CI 2.24–12.10, P < 0.001); three, HR 9.63 (95% CI 4.1–22.60, P < 0.001); and four or more, HR 14.38 (95% CI 5.8–35.65, P < 0.001).
Conclusion
The predictors of mortality have a significant add‐on predictive effect on mortality. The EAARN score could be useful to stratify the prognosis of CRT patients.
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