Bacteremia and infective endocarditis in patients on hemodialysis.

The number of patients with end-stage renal disease (ESRD) has risen dramatically over the last decade. There are 300,000 patients in the United States with ESRD who are receiving hemodialysis (HD), and the incidence is increasing at a rate of 6% to 8% per year. Bacteremia, a prerequisite for infective endocarditis (IE), occurs at a rate of 0.7 to 1.4 episodes per 100 patient-care months. Few other medical conditions, except for chemotherapy-induced neutropenia, immunosuppression, and intravenous drug abuse, are associated with higher rates of bacteremia. IE occurs in approximately 2% to 6% of patients receiving HD. The aim of this article is to review the pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE in patients receiving HD

Primary cardiac tumors.

Primary cardiac tumors are a rare entity compared to tumors that metastasize to the heart. Patients with such tumors may be asymptomatic. Many cases are found incidentally during evaluation of an unrelated medical condition. It is important for the clinician to have a high index of suspicion when evaluating a patient presenting with signs and systemic symptoms concerning possible malignancy, plus cardiac specific symptoms or complications. These can include new onset dyspnea, congestive heart failure, arrhythmias or murmurs varying with body positions. Imaging, particularly the use of echocardiography, remains the cornerstone of diagnosis, and may be combined with new imaging modalities of cardiac CT and MRI. The aim of this paper is to describe the epidemiology and pathophysiology of the various benign and malignant primary cardiac tumors

The correlation of left ventricular hypertrophy with the severity of atherosclerosis and embolic events.

OBJECTIVE: The study was undertaken to assess the correlation between the presence and degree of aortic atheroma with degree of Left ventricular (LV) mass index and subsequent clinical outcomes. MATERIAL AND METHOD: The authors studied the clinical profiles of 87 patients with aortic atherosclerosis and controls, who had undergone TEE between 1995 and 2000. RESULTS: Mean LV mass index was 116 gram/m2 in atherosclerosis group compared to 81 gram/m2 in the control group (p \u3c 0.009). In the atherosclerotic group, there was a close correlation between LV mass index score and severity of the plaque in the aortic arch and descending aorta (p \u3c 0.001, 0.001). The presence of large ulcerated plaque had a significant correlation with stroke (p \u3c 0.002). CONCLUSION: 1) LV mass index correlates with the severity of aortic atheroma. 2) Smoking, elevated mean arterial blood pressure and a high LV mass index score are significantly correlated with large ulcerated plaque and stroke. 3) These findings may in part explain the higher cardiovascular risk in patients with increased left ventricular mass

Epidemiology and outcome of infective endocarditis in hemodialysis patients.

BACKGROUND: Survival in patients with infective endocarditis (IE) ranges from 4 to 50% depending on the type of organism, the type of valve involvement and the type of treatment. METHODS: We conducted a retrospective analysis of data in hemodialysis (HD) patients at our center from 1990 to 2000. Demographics, risk factors, and outcome data were extracted in the subgroup of patients with first-episode IE diagnosed primarily by echocardiography. RESULTS: A total of 2239 patients underwent HD at our center. Thirty-two (1.4%) had IE defined using the Duke Criteria. Permanent and temporary venous dialysis catheters, arteriovenous (AV) grafts, and AV fistulae were used in 19 (59%), 12 (38%), and 1 (3%) patient respectively. Mean access duration was 7.6 +/- 7.9 months. Thirty (94%) patients had positive blood cultures, with the majority having Staphylococcus aureus bacteremia. Two (7%) patients had positive echocardiographic findings but negative blood cultures due to the commencement of empiric antibiotic therapy prior to blood cultures. The mitral valve was mainly affected. Transesophageal echocardiography was performed in 23 (72%) patients and detected an intracardiac mass in all 23 patients. One-year mortality was 56.3%. A poor 1-year prognosis was associated with presenting features of low hemoglobin, elevated leukocyte count, hypoalbuminemia, severe aortic and mitral regurgitation, and annular calcification in mitral valve IE. CONCLUSION: The prevalence of IE in HD patients is 1.4%. One-year mortality was 56.3%. Close observation is required during the first year when patients with severe valvular regurgitation and hematological abnormalities have a high mortality

Penetrating aortic atherosclerotic ulcer complicated by periesophageal hematoma.

Penetrating aortic atherosclerotic ulcers have been recently recognized as an entity among the acute aortic syndromes with a potentially fatal outcome. We describe the case of a patient presenting with severe chest pain who died as a result of a thoracic-aorta penetrating atherosclerotic ulcer complicated by a intramural hematoma of the esophagus and stomach, leading to exsanguination. To our knowledge this is the first case reported in the literature of such a complication from penetrating aortic atherosclerotic ulcers

Inducible left ventricular outflow tract gradient during dobutamine stress echocardiography: an association with intraoperative hypotension but not a contraindication to liver transplantation.

BACKGROUND: Dobutamine stress echocardiography (DSE) is frequently used in the evaluation of cardiac risk prior to orthotopic liver transplantation (OLT). In the general cardiac population, an inducible left ventricular outflow tract gradient (LVOT Delta) during DSE has variable prognostic importance. The purpose of this study was to determine the prevalence and clinical significance of LVOT Delta in patients undergoing OLT during DSE. METHODS: Consecutive medical records of 106 patients who had undergone OLT at our institution from January 1997 until January 2002 were retrospectively analyzed and divided into two groups based on the presence (Group I, LVOT Delta \u3e36 mmHg) or absence (Group II, LVOT Delta\u3c or = 36 mmHg) of a significant LVOT Delta measured during DSE. We determined any outcome differences between these two groups with regard to intraoperative hypotension, cardiac mortality, length of hospital stay, graft function, and renal function post-OLT. RESULTS: Forty-six patients had an LVOT Delta \u3e 36 mmHg (Group I) and 60 patients had LVOT Delta\u3c or = 36 mmHg (Group II). Baseline demographics were similar in both groups. There was no significant overall difference in cardiac mortality between Group I versus Group II patients (0 versus 1 patient, respectively, P=0.57). Intraoperative hypotension occurred in 4 patients in Group I versus 0 patient in Group II (P=0.03). Length of stay, graft function, and postoperative renal function were similar in both groups. CONCLUSION: A significant LVOT Delta \u3e36 mmHg is a frequent finding occurring in 46/106 (43%) of patients who have DSE pre-OLT. Intraoperative hypotension is associated with patients having an LVOT Delta. However, post-OLT patients with significant LVOT Delta have a similar in-hospital outcome compared to patients without significant LVOT Delta

Undefined hypercoaguable state associated with massive right ventricular thrombus and embolism in a previously healthy 17-year-old male.

A right ventricular thrombus (RVT) is an unusual finding on echocardiography. We describe a healthy young male patient who developed RVT with subsequent pulmonary embolism (PE), the etiology of which remains uncertain