Clinical articles

Despite the significant improvements in both diagnostic and therapeutic procedures in recent years, infective endocarditis (IE) remains a medical challenge due to poor prognosis and high mortality. Echocardiographically, the majority of the patients demonstrate vegetations on a single valve, while demonstration of involvement of two valves occurs much less frequently; triple-valve involvement is extremely rare. Reported operative mortality after triple-valve surgery is high and ranges between 20% and 25%. 

Surgical treatment is used in approximately half of patients with IE because of severe complications. Reasons to consider early surgery in the active phase, i.e. while the patient is still receiving antibiotic treatment, are to avoid progressive heart failure and irreversible structural damage caused by severe infection, and to prevent systemic embolism. Prognosis in IE is influenced by four main factors: characteristics of the patient, the presence or absence of cardiac and non-cardiac complications, the infecting organism, and echocardiographic findings. Prognosis of right-sided native valve endocarditis is relatively good, with an in-hospital mortality rate of about 10%.

We present a case of a young man with triple-valve endocarditis followed by a brief review of the literature.

This was a pilot study, in which 55 breast cancer patients were enrolled, to evaluate the alterations of strain and strain-rate parameters in breast cancer patients receiving doxorubicin and compare them with serial conventional echocardiography changes. A week prior to, and a week after, chemotherapy with doxorubicin, left ventricular ejection fraction (LVEF) and strain and strain-rate parameters were measured by conventional 2D echocardiography and tissue Doppler-based imaging, respectively.

Comparison of the results of pre- and post-chemotherapy evaluation demonstrated that strain and strain-rate parameters were significantly reduced. Mean difference (standard deviation) for the strain measurement of basal-septal, basal-lateral, basal-inferior, and basal-anterior values were 2.58% (2.15), 3.20% (1.94), 4.13% (3.48), and 2.86% (2.65), respectively; and for the strain-rate values were 0.18 s^–1 (0.17), 0.17 s^–1 (0.17), 0.24 s^–1 (0.19), and 0.19 s^–1 (0.14), respectively; all p values <0.001. There was no significant change in patients’ LVEF after chemotherapy (pre-intervention 61.10 (4.86), post-intervention 61.06 (4.82), p=0.857). 

In conclusion, strain/strain-rate significant reduction, in the setting of normal range LVEF, suggests subclinical heart failure. Whether the strain and strain-rate imaging should replace the conventional echocardiography for early monitoring of cardiotoxicity of doxorubicin requires further investigations.

A 79-year-old lady was taken to the emergency department by her carer, who had noticed an acute deterioration of her general condition. Unfortunately, it was difficult to obtain an accurate history from the patient due to cognitive impairment, and her carer was not aware of her past medical history. However, she had been observed clenching her hands to her chest. She was not previously known to the admitting hospital.

Current guidelines recommend against vigorous sports for all patients with an implantable cardioverter defibrillator (ICD). In this study, we established the risk of life-threatening arrhythmias and shocks in patients with an ICD participating in sports. 

In this single-centre, cohort survey with 71 patients (59% male) ≤40 years old at ICD implantation and with a left ventricular ejection fraction (LVEF) ≥35%, 16 patients were defined as athlete (exercise ≥5 hours per week). Sports-related and clinical data were obtained using questionnaires and medical records. Median age was 38 years (19–53 years). Median follow-up period was 67 months (11–249 months). Idiopathic ventricular fibrillation (VF) was the most frequent indication (20%) for implantation. There were 22 patients (31%) who experienced 127 shock episodes, of which 112 were appropriate: 15% of shocks occurred during physical exercise. Shocks did not occur more frequently in athletes (25%) compared with non-athletes (33%, p=0.760). Intensity of exercise and appropriateness of shocks were not associated. 

In conclusion, we found no evidence that participation in sports contributed to the risk of life-threatening arrhythmias and (in)appropriate ICD shocks in patients with an ICD. In individual cases, the advice to participate in sports could be more lenient compared with current guidelines.

Current transcatheter mitral valve techniques are at the beginning of an era of innovation before their full potential is realised. The broadening of available options for mitral regurgitation (MR) reduction is welcome and transcatheter mitral valve interventions provide complementary strategies in the drive for more safe and effective therapies for patients. In this article, the evidence and indications for MitraClip^® are reviewed.

Postural tachycardia syndrome (PoTS) is a recently recognised condition that usually affects younger women, who develop symptoms of orthostatic intolerance and a persistent tachycardia on standing upright. Healthcare professionals, patients and the national patient support group (PoTS UK) together created a survey, and the responses of 779 UK PoTS patients were analysed. The most common symptoms of PoTS at presentation were the triad of fatigue, lightheadedness and palpitations. Mobility, ability to work or attend education, and quality of life were significantly restricted. Cardiologists, followed by patients, were most likely to be the first to suggest the diagnosis of PoTS. Patients waited a mean of almost four years from presentation to obtain their diagnosis and, meantime, psychiatric mislabeling was common. Advice given to patients regarding lifestyle changes was variable, and those referred to specialist practitioners for help, found practitioners had limited knowledge about management of PoTS. Increased education of healthcare professionals and improved services for patients are recommended. 

In 2010, the National Institute for Health and Care Excellence (NICE) introduced new guidelines for the assessment of people with recent-onset chest pain, recommending investigations based upon one’s pre-test likelihood of having coronary artery disease. We aim to determine the impact these guidelines have made on the numbers of patients being discharged and referred for further investigations. We retrospectively analysed a database of 337 consecutive patients seen in the rapid access chest pain clinic: 162 patients were seen in the three months preceding, and 175 were seen in the three months following implementation of the new guidelines. We found that after implementation of the new guidelines, fewer patients (25% vs. 37%, p=0.018) were discharged at the first visit, and a greater number of patients were referred for an angiogram (20% vs. 6%, p=0.0001). The number of referrals for stress imaging significantly reduced from 57% to 37%. According to the new guidelines, 18% of patients were referred for coronary calcium scoring. This reflects a definite change in clinical practice with reduced direct discharges from the chest pain clinic, reduced reliance on functional imaging and increased direct referrals for invasive coronary angiography, resulting in higher investigational costs of the chest pain service.

A 90-year-old man with a history of prostate cancer was admitted with haematuria and mild normocytic anaemia on routine blood tests. Baseline observations were normal and chest X-ray was unremarkable. Electrocardiogram (ECG) showed tri-fascicular block. He underwent successful bladder irrigation. Prior to discharge, he suffered a syncopal episode: ECG confirmed tri-fascicular block, for which he was discussed with the cardiology team for consideration of permanent pacemaker implantation. Pre-procedural transthoracic echocardiogram (TTE) revealed a large mobile thrombus attached to the tricuspid valve (TV) and extending to the right ventricle (RV), significant RV impairment and severe TV regurgitation (figure 1A–B). Following discussion between urology and cardiology teams and, in view of the significant risk of massive pulmonary embolism (PE), the patient underwent urgent thrombolysis. This was not complicated by significant haematuria. Post-intervention TTE demonstrated complete dissolution of the right-sided thrombus and mild TV regurgitation only (figure 1C–D). Warfarin was started and no further haematuria or syncope was reported on subsequent follow-up.

A 47-year-old woman had been referred to the cardiology department with a six-month history of intermittent chest discomfort not specifically related to exertion. Her risk factors: current smoker 10–15 per day and family history of ischaemic heart disease. She had no history of diabetes or hypertension. Lipid levels had not been tested. 

Structural heart disease may be missed using clinical examination alone and limited echocardiograms or ‘quick-scans’ may be a way to improve rates of detection. To evaluate the finding of clinically unexpected abnormalities using ‘quick-scans’, scans were performed in a general practice by a level 7 sonographer using a GE V scan system. Indications were: murmur; potentially cardiac symptom (e.g. chest pain or breathlessness); cardiac history in the GP notes (e.g. myocardial infarction); atrial fibrillation; chronic obstructive pulmonary disease with disproportionate dyspnoea; age ≥75 years. Standard transthoracic echocardiograms were performed if clinically indicated or if the ‘quick-scan’ detected a significant abnormality.

There were 163 ‘quick scans’ indicated, which were normal in 80 (49%), mildly abnormal in 67 (41%) and significantly abnormal in 16 (10%). Abnormalities were moderate left ventricular (LV) systolic dysfunction, moderate mitral regurgitation, moderate-to-severe aortic stenosis and mild aortic dilatation. Within the 90 patients without agreed indications the ‘quick-scans’ were normal in 64 (71%) and mildly abnormal in 26 (29%) while none were significantly abnormal.

In conclusion, ‘quick scans’ can detect clinically unexpected pathology. These results are consistent with a global move to use the hand-held ultrasound machine as an extension of the clinical examination.