Letter by Hussain and Bernardo Regarding Article, "Acute Impact of Prone Positioning on the Right Ventricle in COVID-19-Associated Acute Respiratory Distress Syndrome" [Letter]
Invasive Aortic Valve Endocarditis: Clinical and Tissue Findings From a Prospective Investigation
BACKGROUND:Advanced aortic valve infective endocarditis (IE) with progression and destruction beyond the valve cusps-invasive IE-is incompletely characterized. This study aimed to characterize further the invasive disease extent, location, and stage and correlate macroscopic operative findings with microscopic disease patterns and progression. METHODS:A total of 43 patients with invasive aortic valve IE were prospectively enrolled from August 2017 to July 2018. Of these patients, 23 (53%) had prosthetic valve IE, 2 (5%) had allograft IE, and 18 (42%) had native aortic valve IE. Surgical findings and intraoperative photography were analyzed for invasion location, extent, and stage. Surgical samples were formalin fixed and analyzed histologically. The time course of disease and management were evaluated. RESULTS:Pathogens included Staphylococcus aureus in 17 patients (40%). Invasion predominantly affected the non-left coronary commissure (76%) and was circumferential in 15 patients (35%) (14 had prosthetic valves). Extraaortic cellulitis was present in 29 patients (67%), abscess in 13 (30%), abscess cavity in 29 (67%), and pseudoaneurysm in 8 (19%); 7 (16%) had fistulas. Histopathologic examination revealed acute inflammation, abscess formation, and lysis of connective tissue but not of myocardium or elastic tissue. Median time from onset of symptoms to antibiotics was 5 days, invasion confirmation 15 days, and surgery 37 days. Patients with S aureus had a 21-day shorter time course than patients non-S aureus. New or worsening heart block developed in 8 patients. CONCLUSIONS:Advanced invasive aortic valve IE demonstrates consistent gross patterns and stages correlating with histopathologic findings. Invasion results from a confluence of factors, including pathogen, time, and host immune response, and primarily affects the fibrous skeleton of the heart and expands to low-pressure regions.
Minimally Invasive Off-Pump Technique for Temporary Left Ventricular Support
Use of short-term mechanical circulatory support (MCS) for cardiogenic shock has rapidly increased. Most common initial MCS strategies entail institution of peripheral extracorporeal membrane oxygenation (ECMO) or temporary ventricular assist devices. For patients with anatomically small peripheral arteries or insufficient circulatory support, sternotomy and central cannulation techniques may be necessary. These invasive approaches are associated with increased risk of bleeding and other significant complications. We describe a minimally invasive, off-pump technique to provide adequate hemodynamic support and left ventricular unloading, allowing early postoperative ambulation, and ability to easily provide additional right ventricular/ECMO support if needed.
Commentary: Endovascular repair to the rescue! [Editorial]
Commentary: Atrial fibrillation after cardiac surgery: More than just a nuisance! [Editorial]
Patterns of Hepatocellular Carcinoma After Direct Antiviral Agents and Pegylated-Interferon Therapy
INTRODUCTION/BACKGROUND:Â The impact of direct-acting antiviral agents (DAAs) on the development of hepatocellular carcinoma (HCC) is controversial and a part of the scientific community believes it as a biased interpretation of data. Many studies have reported an aggressive pattern of HCC after DAA use. In this study, we attempted to assess the changes in the pattern of HCC after treatment with DAAs or PI (PEG, pegylated-interferon). METHODS:Â A total of 37 HCC patients after DAA treatment and 21 HCC patients after PI treatment were included. The diagnosis of HCC was made and information about demographics, HCC infiltrative pattern, portal vein thrombosis (PVT), time at initial presentation, Child-Turcotte-Pugh (CTP) score, and Barcelona Clinic Liver Cancer (BCLC) stage were compared in the two groups. RESULTS:Â The total number of male patients in the DAA group was 62% while either gender was almost equal in PI. The age group of 40-60 was more prevalent in the DAA group while the PI group comprised more patients who were above 60 years. Patients in the DAA group presented after 3.35 years on average while patients in the PI group presented after about seven years. Most of the patients presented with the CTP stage of A. That is true for both groups. For BCLC staging, most of the patients had stage C, which means multiple lesions. At the initial presentation, most of the patients presented with multifocal lesions. CONCLUSION/CONCLUSIONS:Â Our study found no significant difference in the initial presentation between both groups. However, HCC patients with prior DAA therapy presented early than those with PI therapy.
COVID-19 in recent heart transplant recipients: Clinicopathologic features and early outcomes
BACKGROUND:The impact of COVID-19 on heart transplant (HTx) recipients remains unclear, particularly in the early post-transplant period. METHODS:We share novel insights from our experience in five HTx patients with COVID-19 (three within 2Â months post-transplant) from our institution at the epicenter of the pandemic. RESULTS:All five exhibited moderate (requiring hospitalization, nÂ =Â 3) or severe (requiring ICU and/or mechanical ventilation, nÂ =Â 2) illness. Both cases with severe illness were transplanted approximately 6Â weeks before presentation and acquired COVID-19 through community spread. All five patients were on immunosuppressive therapy with mycophenolate mofetil (MMF) and tacrolimus, and three that were transplanted within the prior 2Â months were additionally on prednisone. The two cases with severe illness had profound lymphopenia with markedly elevated C-reactive protein, procalcitonin, and ferritin. All had bilateral ground-glass opacities on chest imaging. MMF was discontinued in all five, and both severe cases received convalescent plasma. All three recent transplants underwent routine endomyocardial biopsies, revealing mild (nÂ =Â 1) or no acute cellular rejection (nÂ =Â 2), and no visible viral particles on electron microscopy. Within 30Â days of admission, the two cases with severe illness remain hospitalized but have clinically improved, while the other three have been discharged. CONCLUSIONS:COVID-19 appears to negatively impact outcomes early after heart transplantation.
The validity of infrared coagulator, and BioGlue with antibiotics to assist surgical treatment of infective endocarditis? [Comment]
Association of Surgical Treatment With Survival in Patients With Prosthetic Valve Endocarditis
BACKGROUND:Prosthetic valve endocarditis (PVE) is a serious condition with high morbidity and mortality. This study investigated the association of surgical treatment with survival among patients with PVE. METHODS:A retrospective cohort study was done of patients with PVE hospitalized over 8 years in a large referral center. Association of surgery with survival was evaluated with multivariable Cox proportional hazards regression, adjusting for propensity to be accepted for surgery, and analyzing surgery as a time-dependent covariate. Survival was also compared separately in a 1:1 propensity score-matched cohort of patients accepted for surgery and control patients consigned to nonsurgical treatment. RESULTS:Of 523 patients (mean [SD] age, 61  years; 370 [71%] men; 393 [75%] initially accepted for surgery), 404 ultimately underwent surgery and 119 received nonsurgical treatment alone. Surgical treatment was associated with significantly lower hazard of death in the entire cohort (hazard ratio [HR]Â = 0.32; 95% confidence interval [CI]: 0.22-0.48; P < .001) and in the 1:1 matched cohort (HRÂ = 0.33; 95% CI: 0.19-0.57; P < .001). Initial acceptance for surgery was associated with significantly lower odds of in-hospital death (odds ratio [OR]Â = 0.26; 95% CI: 0.11-0.59; P < .001), death or readmission within 90 days (ORÂ = 0.17; 95% CI: 0.07-0.43; P < .001), and death within 1 year (ORÂ = 0.16; 95% CI: 0.08-0.34; P < .001). CONCLUSIONS:Surgical treatment is associated with a large survival benefit in PVE. A decision to pursue nonsurgical treatment in PVE should entail close follow-up for any development of an indication for surgery.
Invited Commentary [Comment]