Theodore Addai

Intravenous drug use is an increasingly common condition predisposing to infective endocarditis. Data on infective endocarditis in intravenous drug users are limited. To determine the clinical features, bacteriologic findings, site of involvement, complications, and mortality associated with infective endocarditis in intravenous drug users. Cohort study of intravenous drug users with native valve infective endocarditis. A total of 125 cases of infective endocarditis occurred in 114 patients (84 cases [67%] in men and 41 cases [32%] in women) with a mean (+/- SD) age of 37 +/- 7 years. The tricuspid valve was involved in 58 cases (46%), the mitral valve in 40 cases (32%), and the aortic valve in 24 cases (19%). The microorganisms identified included Staphylococcus in 82 cases (65.6%) and Streptococcus in 32 cases (25.6%). Twenty-three patients (18%) underwent surgery, and two (9%) of them died. One hundred two patients (82%) were treated medically, and nine (9%) of them died. Fifteen patients (63%) with aortic valve involvement vs 17 patients (17%) without aortic valve involvement underwent surgery or died without surgery (odds ratio, 8.24; 95% confidence interval, 3.1 to 21.8). Among the survivors, at least one major cardiovascular complication occurred in 79 cases (69.3%). Infective endocarditis in intravenous drug users affects the right and left sides of the heart with approximately equal frequency. At present, more than 90% of cases of infective endocarditis in intravenous drug users in Chicago are caused by staphylococci or streptococci. Involvement of the aortic valve is predictive of increased morbidity and mortality in intravenous drug users with infective endocarditis. With medical treatment, and surgery when medical treatment fails, intravenous drug users with infective endocarditis have an in-hospital survival rate of 91%.

An 82-year-old female with history of hyperlipidemia and hypertension presented to the clinic with chief complaint of nonradiating chest tightness accompanied by exertional dyspnea. Cardiac catheterization showed the absence of left coronary system; the entire coronary system originated from the right aortic sinus as a common trunk which then gave off the right coronary artery and the left main coronary artery. Cardiac catheterization demonstrated also another rare coronary anomaly: dual left anterior descending artery. Patient underwent percutaneous coronary intervention and subsequent multidetector computed tomography angiography confirmed the above angiography findings. Patient was subsequently discharged home on double antiplatelet therapy with aspirin and clopidogrel and has been asymptomatic since then.

Background and aim of the study: A retrospective evaluation was made of a small personal series of patients undergoing mitral valve repair in order to address four contemporary questions: (i) What is the best method of achieving a stable repair in mitral valve prolapse?; (ii) How should patients with pure annular dilatation without prolapse or antecedent ischemia be categorized?; (iii) Are valve procedures in ischemic mitral regurgitation (MR) still associated with less satisfactory early and late outcomes?; and (iv) Is prophylactic amiodarone therapy safe and effective in reducing postoperative arrhythmias? Methods: Between 1993 and 2002, a total of 118 patients with non-rheumatic MR undergoing isolated mitral valve repair with or without coronary bypass was analyzed retrospectively: of these patients, 66 had prolapse (Group I), 21 had pure annular dilatation (Group II), and 31 had ischemic MR (Group III). All three groups routinely underwent Carpentier ring annuloplasty. Twenty-three patients in Group I were managed with leaflet resection and reconstruction (LRR), but in 1996 the technique for Group I was changed to uniform artificial chordal replacement (ACR) and no leaflet resection (n = 43). Also in 1996, prophylactic amiodarone therapy was first used routinely, and postoperative arrhythmia data were compared to those from prior patients. Baseline and outcome variables were assessed for each group and compared between the three groups. Survival data were evaluated using the Cox proportional hazards model. Results: Significant differences in baseline characteristics were observed: Group II was predominantly female; Group III more often experienced acute presentation; and Groups II and III had more comorbid disorders and left ventricular dysfunction (all p < 0.01). ACR was highly successful for repair of prolapse, and no ACR patient exhibited significant residual MR or outflow tract obstruction. Operative mortality and morbidity were low in all groups, and ischemic etiology failed to be an independent predictor of early or late adverse outcome (p > 0.10). Cox model analysis to nine years of follow up (median 4 years) identified only advanced age and number of comorbidities as influencing late mortality (both p < 0.03). Over the follow up period, 8.7% of LRR patients required reoperation for valve failure due to late chordal rupture, whereas none of the ACR patients failed. Finally, prophylactic amiodarone significantly reduced postoperative arrhythmias (p = 0.03) with no observed complications, and also eliminated death due to arrhythmia. Conclusion: Ischemic etiology may be diminishing as an independent risk factor in Group III, at least partially because of uniform valve repair. Group II comprised a distinct entity of females with higher comorbidity, and prophylactic amiodarone therapy seemed useful as a routine measure. Finally, ACR appeared to produce a stable repair in virtually all Group I patients, suggesting that prolapse might be appropriately managed with ring annuloplasty and uniform ACR. However, future studies are suggested for further consideration of these hypotheses.

Echocardiography allows the detection of vegetations and estimation of valvular dysfunction in patients with infective endocarditis. The value of echocardiographic findings in predicting cardiac and other vascular complications in infective endocarditis is not well understood. Identification of high-risk patients and early surgery may improve their prognosis. The authors reviewed echocardiographic findings and related them to the development of congestive heart failure, systemic embolism, and the need for surgery or the risk of death without surgery in patients with infective endocarditis. There were 125 episodes of endocarditis in 114 patients (84 episodes [67%] in men) with a mean age +/- standard deviation of 37 +/- 7 years. Vegetations were detected by echocardiography on at least 1 valve in 87 episodes (70%); on the mitral valve in 36 episodes (29%); on the aortic valve in 21 episodes (17%); and on the tricuspid valve in 45 episodes (36%). Severe aortic regurgitation was present in 9 episodes (7%) and severe mitral regurgitation in 4 instances (3%). In 12 of 21 episodes (57%) of vegetations on the aortic valve compared with 15 of 104 patients (14%) without vegetations on the aortic valve (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and in 8 of 9 instances (89%) of severe aortic regurgitation compared with 19 of 116 episodes (16%) without severe aortic regurgitation (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.00001), the patients developed congestive heart failure. In 18 of 55 episodes (33%) of vegetations on the aortic/mitral valve compared with 17 of 70 episodes (25%) without vegetations on the aortic valve/mitral valve (p = NS), the patients developed systemic embolism. In 13 of 21 episodes (62%) of vegetations on the aortic valve compared with 19 of 104 episodes (19%) without vegetations on the aortic valve (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and in 8 of 9 episodes (89%) of severe aortic regurgitation compared with 24 of 116 episodes (21%) without severe aortic regurgitation (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.00001), the patients either had surgery or died without surgery. Echocardiographic findings do not reliably predict the risk of systemic embolism in patients with infective endocarditis. Vegetations on the aortic valve and severe aortic regurgitation detected by echocardiography predict a high risk of developing congestive heart failure, and for the combined outcome of requiring surgery, or dying without surgery in infective endocarditis. Early surgery may improve the outlook for survival of these patients.