Novel Application of Tissue Doppler Imaging: A Preliminary Observational Study

Tissue Doppler imaging was used with transthoracic and transesophageal echocardiography to determine its clinical usefulness beyond visualization of ventricular wall motion. Thirteen novel applications were found: acoustically difficult transthoracic studies, thrombus, mitral chordal motion, shunt detection using saline contrast, spontaneous echo contrast, intra-aortic balloon pump position and function, endocarditis (prosthetic and native), valve strands (prosthetic and native), mobile aortic atheroma, prosthetic valve motion, aortic valve motion in the presence of a calcified aortic annulus, systolic anterior motion of the mitral valve, and cardiac tumors. Tissue Doppler imaging directly affected the ability to make difficult diagnostic decisions with increased confidence and reduced the need for additional studies.     

Novel Application of Tissue Doppler Imaging

Tissue Doppler imaging was used with transthoracic and transesophageal echocardiography to determine its clinical usefulness beyond visualization of ventricular wall motion. Thirteen novel applications were found: acoustically difficult transthoracic studies, thrombus, mitral chordal motion, shunt detection using saline contrast, spontaneous echo contrast, intra-aortic balloon pump position and function, endocarditis (prosthetic and native), valve strands (prosthetic and native), mobile aortic atheroma, prosthetic valve motion, aortic valve motion in the presence of a calcified aortic annulus, systolic anterior motion of the mitral valve, and cardiac tumors. Tissue Doppler imaging directly affected the ability to make difficult diagnostic decisions with increased confidence and reduced the need for additional studies.     

Use of intra-cardiac ultrasound in the diagnosis of prosthetic valve malfunction.

A 46-year old lady was under regular follow up for aortic valve replacement done in 2002 for aortic stenosis. The valve was a Carbomedics 19 mm bi-leaflet aortic valve prosthesis for which she had adequate anticoagulation since implantation. She had a past history of end stage renal failure, type 2 diabetes, hypertension, cerebrovascular disease and systemic lupus erythematosus. She was asymptomatic and had a routine transthoracic echocardiogram performed which revealed that her aortic valve prosthesis was well seated with an elevated velocity across the valve; the aortic valve leaflets were poorly visualised but appeared to be mobile. A transoesophageal echocardiogram (TOE) confirmed the markedly increased forward velocity across the aortic valve (maximum velocity 4.6 m/s) with small aortic root raising the possibility of pressure recovery phenomenon. Once again the leaflets were not clearly seen but appeared mobile despite the use of deep trans-gastric view. Fluoroscopy was performed and revealed that one of the leaflets was not moving. The patient had an intra-cardiac ultrasound scan (ACUSON AcuNav; Siemens) with the probe of the scanner within the right atrium. A long-axis view demonstrated the prosthetic aortic valve leaflets clearly (Fig. 1). A short-axis view of the prosthetic valve revealed an echogenic area at the six o'clock position; this may be due to pannus formation (Fig. 2); colour flow across the valve during systole revealed absence of colour flow though one of the leaflets due to the leaflet being stuck (Fig. 3). The sewing cuff of the Carbomedics valve is coated with biolite carbon, which is an anti-thrombotic agent that prevents adhesion of thrombus or pannus on the sewing cuff. There are few reports of Carbomedics valve dysfunction by pannus formation in the mitral position but none in the aortic position. Fluoroscopy can be used to visualize mobility of valve leaflets but is unable to identify thrombus/pannus formation that may be causing the valve to stick. Intra-cardiac echocardiography (ICE) can provide additional information regarding potential causes of valve dysfunction such as pannus/thrombus formation. However, ICE does suffer from the same limitations as TOE in obtaining sufficiently adequate images of the aortic valve to allow appropriate assessment of leaflet motion and insight into flow channels; it is also more invasive and expensive compared with other imaging modalities. In our patient ICE provided better images than TOE, possibly due to the closer proximity of the probe to the aortic root compared with TOE. ICE is a novel tool in the assessment of prosthetic valve function, which can complement data obtained from transthoracic/transoesophageal echocardiography and fluoroscopy.     

Native aortic valve thrombus as a source of embolisation into the coronary artery

Authors present the case of 66-year-old patient after repeated systemic embolisations (lower extremity, axillary artery), admitted for inferior myocardial infarction. Coronary angiography demonstrated peripheral subtotal occlusion of posterior descending artery (PDA) of embolic origin. Transoesophageal echocardiography (TOE) revealed mobile mass on aortic valve, which was subsequently extirpated surgically. Histological examination described thrombus. Case report depicts the native aortic valve thrombus as a rare source of systemic or coronary embolisation. It simultaneously supports the indication of TOE at systemic embolisations of unknown source, even if transthoracic echocardiography (TTE) finding is normal, and shows its key role in diagnostic algorithm in similar events.     

Maternal and fetal outcomes in pregnant females with rheumatic heart disease

BackgroundCardiac diseases are seen in 1–3% of pregnancies. In developing countries rheumatic heart disease (RHD) contributes a major cause of cardiac disorders.ObjectiveTo study the maternal and fetal outcome in women with valvular heart disease or prosthetic heart valve replacement secondary to RHD in a tertiary care center.MethodThe consecutive pregnant women with RHD attending our institute from May 2018 to August 2019 were included. A maternal adverse outcome was defined as cardiac death, new onset arrhythmia, heart failure, thromboembolic event, hospitalization for other cardiac reasons or cardiac intervention, aortic dissection, infective endocarditis and acute coronary syndrome. Fetal adverse outcome defined as fetal death, preterm birth, and low birth weight.ResultTotal 80 patients were included in this study, native RHD in 60(75%) and 20(25%) had mechanical prosthetic valve replacement. Maternal adverse event occurred in 34(42.5%), comprising of death in 1(1.2%), new onset AF 2(2.5%), 20(25%) underwent balloon mitral valvotomy, 3(3.7%) underwent mitral valve replacement, heart failure hospitalization in 7(8.7%). 1(1.2%) patient developed mitral valve infective endocarditis. Preterm delivery occurred in 19(23.7%), 7(8.7%) abortions and 1(1.2%) intrauterine death. Fetuses with low birth weight were 43(53.7%). Pregnancy with live birth occurred in 57(95%) women with valvular heart disease but no prosthesis and 16(80%) women with prosthetic valve disease.ConclusionWomen with rheumatic heart disease carry a high risk both for mother and fetus. Early diagnosis, close follow-up during pregnancy, early recognition of deterioration in symptoms and timely cardiac intervention can lead to good maternal or fetal outcome.     

食管超声心动图在重危心脏病人诊断治疗中的价值

目的　为评价食管超声心动图 (TEE)在重危心脏病人诊断治疗中的价值 ,对 3 7例收住监护病房的重症心血管病人进行了经胸超声心动图 (TTE)和TEE检查 ,其中男 2 5例 ,女 1 2例 ,平均年龄57( 1 9～ 85)岁。入选对象包括怀疑夹层动脉瘤 2 3例、心脏瓣膜功能异常 9例、感染性心内膜炎 3例 ,心内分流 2例。结果　所有病人均可耐受TEE检查 ,无并发症发生 ,TEE较TTE可提供更高的阳性诊断结果 ,阳性率分别为 65 0 %和 3 8 0 % ,在怀疑夹层动脉瘤者中 ,TEE检出夹层撕裂膜 1 4例 ;而TTE仅检出 7例 ,且图象欠清 ,检出部位有限。在 4例人工机械瓣膜功能异常者中 ,TEE发现瓣膜部位血栓形成 3例。结论　在对心脏大血管疾病的诊断中 ,TEE阳性诊断率高于TTE ,尤其在怀疑夹层动脉瘤及人工机械瓣膜病变时 ,应行TEE检查。即使在重危病人 ,TEE也是一种安全有效的诊断手段。     

Stenotrophomonas maltophilia endocarditis: a systematic review

The disease characteristics, management, and outcome of Stenotrophomonas maltophilia endocarditis were evaluated by examining the reports on the subject identified through a comprehensive literature search. Twenty-three (17 male) cases of S.. maltophilia endocarditis were identified. Mean age was 41 +/- 15 years. All patients presented with fever. Prosthetic valves were involved in 12 (52%) cases. Among native valves, the aortic valve was most frequently involved (50%), followed by the tricuspid valve (36%). Twenty (87%) patients had underlying risk factors for the development of endocarditis, including prior valvular or congenital heart disease surgery (60%), intravenous drug abuse (32%), and infected intravascular lines (18%). The endocarditis was postoperative in 14 patients. Seventeen (74%) patients experienced complications including septic embolism (23%), cardiac abscesses (23%), and congestive heart failure (18%). A combination of two or more antibiotics was used in all cases except one. The frequently used antibiotics were aminoglycosides (59%), trimethoprim-sulfamethoxazole (48%), and penicillins (48%). One half of the patients required cardiac surgery, but the proportion of surgically treated cases was higher among prosthetic valve endocarditis (62%). Mortality was 39% and was equally distributed between patients with prosthetic and native valve endocarditis. The S. maltophilia endocarditis carries high complication and mortality rates. The antibiotic regimen should consist of a combination of multiple antibiotics guided by the sensitivity panel. Early surgery may be considered in patients not responding to antibiotic treatment and in those with prosthetic valve endocarditis.     

Diagnostic value of D-dimer and antithrombin-III levels in predicting prosthetic heart valve thrombosis

The aim of this prospective study was to investigate the diagnostic value of plasma D-dimer levels and antithrombin-III activity in predicting prosthetic valve thrombus. The study group comprised 97 consecutive patients with prosthetic heart valves (59 with mitral, 21 with aortic, and 17 with both mitral and aortic prostheses) and 35 healthy control subjects. Six patients presented with symptoms of obstruction; the remaining 91 were asymptomatic. Patients were evaluated by both transthoracic and transesophageal echocardiography. Asymptomatic nonobstructive thrombus was detected in 13 patients (13%), whereas obstructive thrombus was demonstrated in all symptomatic patients. Plasma antithrombin-III levels of patients with prosthetic valve thrombi were slightly lower than those of patients without thrombus and of the control group, but the difference was not statistically significant. However, significantly higher plasma D-dimer levels were observed in patients with prosthetic valve thrombi, compared with patients without thrombus and the control group (735 +/- 633 microg/L, 372 +/- 342 microg/L, and 228 +/- 219 microg/L, respectively). Valve thrombus, the prosthetic heart valve itself, and INR levels were identified as major determinants of plasma D-dimer levels. A plasma D-dimer level of >445 microg/L predicted the presence of a prosthetic valve thrombus with 57.8% sensitivity and 83.3% specificity (positive predictive value, 47.8%; negative predictive value, 87.8%). Current data suggest that increased plasma D-dimer levels can be clinically helpful in predicting the presence of prosthetic valve thrombus. Plasma antithrombin-III activity does not seem to have a diagnostic value in predicting prosthetic valve thrombi.     

Unstable angina secondary to left main coronary thrombus extending from prosthetic aortic valve

Embolic complications due to prosthetic heart valves are common. The present report documents a left main coronary artery thrombus extending from a Starr Edward's aortic ball valve prosthesis 22 years after its placement. It resulted in unstable angina and a small myocardial infarction. This rare complication illustrates the importance of adequate anticoagulation.     

Spontaneous native aortic valve thrombosis

Spontaneous thrombosis of a native aortic valve is an uncommon event that usually follows local trauma, such as cardiac surgery or left heart catheterization, or occurs as a complication of bacterial endocarditis. We report the case of a 65-year-old woman with a history of retinal artery occlusion and severe aortic valve stenosis, in whom transesophageal echocardiography revealed a mobile mass attached to the ventricular surface of the aortic valve. There was no evidence of any hypercoagulable state or infection process. Surgery was performed and a severely stenotic valve resected; a partially organized and firmly adherent free-floating thrombotic mass was observed on the ventricular surface of the aortic valve. Histologic examination demonstrated an organized thrombus. Eleven months after surgery the patient is doing well.     

Thrombotic occlusion of an aortic-root xenograft during left ventricular assistance

A 45-year-old man underwent repair of a congenital bicuspid aortic valve and complex aortic-root aneurysm with an aortic-root xenograft. A CentriMag® left ventricular assist device was implanted for cardiac support and was subsequently replaced with a HeartMate II® left ventricular assist device. A day later, the patient was returned to the operating room for control of bleeding, and thrombotic occlusion of the prosthetic aortic valve was detected. The patient underwent thrombus removal, oversewing of the prosthetic valve, and bypass of the left anterior descending coronary artery. This case emphasizes the hazard of bypassing a failed left ventricle with a cardiac assist device after aortic valve replacement, even with a bioprosthesis.Key words: Aorta/surgery, aortic arch/surgery, aortic root/surgery, aortic valve replacement, heart valve prosthesis, postoperative complications, thrombosis, ventricle assist devicesPostcardiotomy support with a left ventricular assist device (LVAD) after aortic valve and aortic root replacement presents a unique challenge. Even in the presence of a prosthetic aortic valve, aortic-root stasis can result in valve thrombosis. We describe the case of a patient who had thrombosis of an aortic-root xenograft during LVAD support after undergoing repair of a complex aortic aneurysm.     

Echocardiographic and clinical correlations in infectious endocarditis of the left heart

The echocardiographic features were correlated with the clinical findings and outcome in 35 patients with aortic and/or mitral valve endocarditis. There were 26 males and 9 females with a mean age of 38 years. The infection involved native valves in 27 patients and prosthetic valves in 8 patients. Echocardiographically, fourteen patients had involvement of native aortic valve. All patients in this group required surgical intervention, nine patients during antimicrobial therapy. Congestive heart failure was the clinical indication for valvular replacement. A patient died immediately after surgery from low cardiac output syndrome. Six patients had echocardiographic evidence of aortic and mitral valves involvement. A patient in this group expired before surgery, five underwent surgery because of progressive heart failure (aortic or aortic and mitral valves replacement). Seven patients showed lesions on native mitral valve (6 in this group had prolapse syndrome). A patient died from cerebrovascular embolus, two underwent surgery because of persistent infection and embolic events, four were successfully treated with medical therapy. Among patients with prosthetic valve endocarditis, four showed signs of valvular dehiscence and required surgical intervention, during antimicrobial therapy, from congestive heart failure; one patient expired from recurrent infection. The pathological findings correlated well with echocardiographic findings. Conclusions: in IE the localization of lesions by echo has prognostic significance: most patients with aortic valve or aortic and mitral valves endocarditis require early surgical intervention because of congestive heart failure. On the contrary, mitral valve involvement carries a better prognosis, requiring less frequently valvular replacement; the patients with echocardiographic signs of prosthetic valve dehiscence require urgent intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Aortic Valve Leaflet Replacement with Bovine Pericardium to Preserve Native Dynamic Capabilities of the Aortic Annulus

Valve replacement is typically the most appropriate option for treating aortic valve stenotic insufficiency. However, neither mechanical nor bioprosthetic replacement components preserve the circumferential expansion and contraction of a native aortic annulus during the cardiac cycle, because the prosthetic ring is affixed to the annulus.A 64-year-old man presented with a bicuspid and stenotic aortic valve, and the native annulus was too small to accommodate a porcine replacement valve. We fashioned new aortic leaflets from bovine pericardium with use of a template, and we affixed the sinotubular junction with use of inner and outer stabilization rings. Postoperative echocardiograms revealed coaptation of the 3 new leaflets with no regurgitation. At the patient''s 5.5-year follow-up examination, echocardiograms showed flexible leaflet movement with a coaptation height of 7 mm, and expansion and contraction of the aortic annulus similar to that of a normal native annulus. The transvalvular pressure gradient was insignificant. If long-term durability of the new leaflets is confirmed, this method of leaflet replacement and fixation of the sinotubular junction might serve as an acceptable alternative to valve replacement in the treatment of aortic valve stenosis. We describe the patient''s case and present our methods and observations.Key words: Aortic valve/physiology/surgery, aortic valve stenosis/surgery, biomechanics, heart valve prosthesis implantation, prosthesis design, treatment outcomeMore aortic valve diseases are treated by means of valve replacement than by valve repair. Replacement, whether with a mechanical or bioprosthetic valve, does not preserve the dynamic changes of the native aortic annulus during the cardiac cycle, because the prosthetic ring is affixed to the annulus. In addition, leaflet motion and area are limited by the 3 stent-posts of a tissue valve or by the ring of a mechanical valve. Consequently, prosthetic valves retain only the opening-and-closing function of the leaflets, and not annular contraction or expansion, during the cardiac cycle. If leaflet replacement alone is performed in the treatment of aortic valve disease, the dynamic functioning of the aortic annulus is expectedly preserved. In a patient who had a bicuspid and stenotic aortic valve, we performed leaflet replacement that involved the use of bovine pericardium and fixation of the sinotubular junction (STJ). We examined leaflet movement and annular dynamic capability during a 5.5-year follow-up period, and we report the case and our findings.     

Results of video-assisted mitral surgery in a non-selected population

A prospective 'analysis of operative risk and results in video-assisted mitral valve surgery performed in a non selected population is reported. Seventy two consecutive patients (1997-2004) with mean age 60 +/- 12 years underwent a video-assisted mitral valve procedure using a femoral CPB. A transthoracic direct aortic clamping was done in 28 patients (TT) and an endo-aortic occlusion balloon was used in 44 patients (Endo). The surgical approach was a right lateral minithoracotomy in all cases; 16 patients had a previous cardiac surgery. The expected mitral operation (39 repairs, 33 replacements) was done in all cases, without conversion. There were 4 early deaths (1 st month), all in Endo group: 1 aortic dissection, 1 heart failure and 2 sudden deaths. Postoperative complication occurred in 17 patients with 5 reoperations for hemostasis of the thoracic wall. Cumulative rate of mortality and morbidity was 29% in Endo and 28% in TT (ns). Hospital stay was 8 +/- 2 days. At discharge, 4 patients had a residual grade 2 echocardiographic mitral regurgitation after valve repair. In January 2005, with a 1.8 years follow-up, there were 4 late deaths, 3 patients underwent a valve reoperation, 2 patients were still in NYHA class 3 and 5 patients had a residual grade 1 or 2 mitral regurgitation. The 3-year actuarial survival was 86 +/- 10% and the 3-year probability to be free of reoperation was 95 +/- 6%. In mitral valve surgery, video-assisted approach is reliable, the operative risk is controlled and midterm results are not compromised. Video-assisted mitral valve surgery is a new less invasive standard; it is the procedure of choice in valve replacement, in reoperation and in non complex valve repair with good cosmetic results.     

Importancia clínica de la insuficiencia cardiaca congestiva en la endocarditis protésica. Estudio multicéntrico de 257 pacientes

Introduction and objectives

There have been no studies conducted in the past that focus on the significance of congestive heart failure in patients with prosthetic valve endocarditis. We studied the incidence of congestive heart failure in patients with prosthetic valve endocarditis and analyzed its profile. In this study, we addressed the prognostic significance of heart failure in patients with prosthetic valve endocarditis and analyzed its outcome based on chosen therapeutic strategies.

Methods

A total of 639 episodes of definite left-sided endocarditis were prospectively enrolled. Of them, 257 were prosthetic. Of the 257 episodes, 145 (56%) were diagnosed with heart failure. We compared the profiles of patients with prosthetic valve endocarditis based on the presence of heart failure, and performed a multivariate logistic regression model to establish the prognostic significance of heart failure in patients with prosthetic valve endocarditis and identified the prognostic factors of in-hospital mortality in these patients.

Results

Persistent infection (odds ratio=3.6; 95% confidence interval, 1.9-6.9) and heart failure (odds ratio=3; 95% confidence interval, 1.5-5.8) are the strongest predictive factors of in-hospital mortality in patients with prosthetic valve endocarditis. The short-term determinants of prognosis in patients with prosthetic valve endocarditis and heart failure are persistent infection (odds ratio=2.8; 95% confidence interval, 1.2-6.5), aortic involvement (odds ratio=2.5; 95% confidence interval, 1.1-5.8), abscess (odds ratio=3.6; 95% confidence interval, 1.4-9.5), diabetes mellitus (odds ratio=2.9; 95% confidence interval, 1.1-7.7), and cardiac surgery (odds ratio=0,2; 95% confidence interval, 0,1-0,5).

Conclusions

The incidence of heart failure in patients with prosthetic valve endocarditis is very high. Heart failure increases the risk of in-hospital mortality by threefold in patients with prosthetic valve endocarditis. Persistent infection, aortic involvement, abscess, and diabetes mellitus are the independent risk factors associated with mortality in patients with prosthetic valve endocarditis and heart failure; however, cardiac surgery is shown to decrease mortality in these patients.Full English text available from:www.revespcardiol.org/en     

Discrepancies Between Doppler- and Catheter-Derived Gradients in Aortic Prosthetic Valves:

Doppler- and catheter-derived gradients have correlated well in patients with native aortic valvular stenosis. This relationship, however, is less certain in the presence of prosthetic aortic valves. We report a case with prosthetic aortic valve in which the echocardiogram suggested significant mechanical valve stenosis. The patient had no evidence of prosthetic valve dysfunction during cardiac catheterization. We conclude that Doppler-derived gradients across prosthetic aortic valves should be correlated with the patient's clinical condition and supplemented by additional noninvasive and invasive data obtained during cardiac catheterization when warranted.
prosthetic aortic valves, Doppler, cardiac catheterization     

Two years' experience with the duromedics bileaflet heart valve prosthesis

The new Duromedics Bileaflet Cardiac Valve prosthesis has a special moving hinge mechanism for its two leaflets to wash the critical articulation area and thus reduce thrombus formation. Between October 1983 and June 1985, we implanted 278 of these prostheses in 254 patients. We did 114 aortic valve replacements, 109 mitral valve replacements, 34 double valve replacements, and two tricuspid valve replacements. Nearly 20% of the patients had had previous cardiac procedures. The hospital mortality was 5.9%. Follow-up was started with 214 surviving Austrian patients, and up to the present time, we have a follow-up period of 1704 patient months. Five patients died late after the operation (3.5 per 100 patient years). We observed 10 valve-related complications in nine patients (7 per 100 patient years). There were three cases of prosthetic endocarditis (2.1 per 100 patient years), two paravalvular leaks, and four bleeding episodes (2.8 per 100 patient years). The mechanical hemolysis was minimal, and the postoperative hemoglobin value averaged 15 g%. The LDH increased from 230 IU to 307 in the aortic valve replacements, 406 in the mitral valve replacements, and 435 in the double valve replacements. Intraoperative pressure gradients and postoperative Doppler echocardiography showed good hemodynamic performance. We conclude that good clinical results and a low complication rate can be achieved with the Duromedics Valve.     

Long-term results after aortic valve replacement in patients with congestive heart failure. Homografts vs prosthetic valves.

OBJECTIVES: The aim of this study was to assess the influence of valve substitute (homograft vs prosthetic valve) on the long-term survival and late valve-related complication rates following aortic valve replacement in patients with aortic valve disease and congestive heart failure. BACKGROUND: The effect of choice of valve substitute on outcome after aortic valve replacement in patients with pre-operative heart failure is unknown. The superior haemodynamic profile of homografts may be of particular benefit. METHODS: We retrospectively analysed pre-operative, operative and follow-up data on 518 adults in functional classes III and IV, who, over the 25 years 1969-1993, had their initial aortic valve replacement at Harefield hospital. Follow-up conducted during 1996 to April 1997 and totalling 4439 patient-years was 96.1% complete. Using multivariate analysis, independent risk factors for different complications and mortality were defined. RESULTS: Overall 5-, 10- and 20-year survival was 80+/-2%, 62+/-2% and 30+/-3%, respectively, with no significant difference between valve types. However, homografts (n=381) independently reduced the rate of serious complications and cardiac death, whereas mechanical valves were an independent adverse risk factor for late mortality. The rates of anticoagulant-related bleeding and thromboembolism were increased by mechanical valves, whereas primary tissue failure was the main complication of homografts. CONCLUSIONS: Long-term outcome of homograft aortic valve replacement in patients with congestive heart failure is acceptable, with a reduced rate of serious complications and cardiac death. Further improvements would be expected if the rate of primary tissue failure could be reduced.     

The role of echocardiography and CT angiography in transcatheter aortic valve implantation patients

The transcatheter aortic valve implantation (TAVI) consist an alternative treatment in patients with severe aortic stenosis. Multimodality imaging using transthoracic echocardiography (TTE) or transesophageal echocardiography (TOE) and multislice CT (MSCT) constitute cornerstone techniques for the pre-operative management, peri-procedural guidance, follow up and recognition of possible transcatheter valve related complications. CT angiography is much more accurate regarding the total definition of aortic annulus diameter and circumferential area. Two-dimensional (2D) echocardiography, underestimates the aortic valve annulus diameter compared to 3D imaging techniques (MSCT, MRI and 3D TOE). Three-dimensional TOE imaging provides measurements of the aortic valve annulus similar to those delivered by MSCT. The pre-procedural MSCT constitutes the gold standard modality minimizing the presence of paravalvular aortic regurgitation, one of the most frequent complications. TOE/TTE and MSCT performance could predict the possibility of pacemaker implantation post-procedural. The presence of a new transient or persisting MR can be assessed well by TOE. Both TTE and TOE, consist initially the basic examination for post TAVI evaluation. In case of transcatheter heart valve failure, the MSCT could be used as additional imaging technique.     

A six years review on 53 cases of infective endocarditis: clinical, microbiological and therapeutical features

Microbiological features, diagnostic investigations, treatment, and complication rate in 53 cases of infective endocarditis were reviewed in this study. Infection occurred both on prosthetic (47%) and native valves (38%), while in 15% of the cases no prior valvular disease was known. Streptococcal (38%) and staphylococcal (30%) infections were predominant. In 17% of the cases apparent negative blood cultures were obtained. The most frequent portal of entry was dental infection or manipulation (45%), however in 28% of the patients etiology remained obscure. Major clinical signs and symptoms included heart murmurs (96%), fever (91%), dyspnoea (32%), and splenomegaly (30%). Echocardiography revealed vegetations in 78%, aortic and mitral valve being nearly equally affected. All patients were medically treated and 53% received antibiotics prior to blood cultures. Associations of ampicillin or penicillin with an aminoglycoside (43%) and penicillinase-resistant antibiotics (30%) were most frequently administered. In 28% of the patients, it was necessary to insert a prosthetic (aortic or mitral) valve. During follow-up, heart failure (28%), embolization (11%), and infections (11%) were the major complications.