[Show abstract][Hide abstract] ABSTRACT: Background. There is an urgent need for alternative rescue therapies in invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA). We assessed the clinical efficacy and safety of the combination of fosfomycin and imipenem as rescue therapy for
MRSA infective endocarditis and complicated bacteremia.
Methods. The trial was conducted between 2001 and 2010 in 3 Spanish hospitals. Adult patients with complicated MRSA bacteremia or
endocarditis requiring rescue therapy were eligible for the study. Treatment with fosfomycin (2 g/6 hours IV) plus imipenem
(1 g/6 hours IV) was started and monitored. The primary efficacy endpoints were percentage of sterile blood cultures at 72
hours and clinical success rate assessed at the test-of-cure visit (45 days after the end of therapy).
Results. The combination was administered in 12 patients with endocarditis, 2 with vascular graft infection, and 2 with complicated
bacteremia. Therapy had previously failed with vancomycin in 9 patients, daptomycin in 2, and sequential antibiotics in 5.
Blood cultures were negative 72 hours after the first dose of the combination in all cases. The success rate was 69%, and
only 1 of 5 deaths was related to the MRSA infection. Although the combination was safe in most patients (94%), a patient
with liver cirrhosis died of multiorgan failure secondary to sodium overload. There were no episodes of breakthrough bacteremia
Conclusions. Fosfomycin plus imipenem was an effective and safe combination when used as rescue therapy for complicated MRSA bloodstream
infections and deserves further clinical evaluation as initial therapy in these infections.
[Show abstract][Hide abstract] ABSTRACT: There is scarce information about the incidence, associated factors and prognosis of pericardial effusion (PE) in patients with infective endocarditis (IE). From 1990 to 2007, patients with native valve IE in our center were prospectively follow-up. A logistic regression analysis was performed to identify independent variables associated to PE and mortality. We included 479 episodes of IE in 459 patients (70% men and mean age 51 years). Small-moderate PE was observed in 109 episodes (23%) and large-very large in 9 episodes (2%). Patient with small-moderate PE when compared with patients without PE had a higher prevalence of intravenous drug abuse history (38% vs. 23%) and had more frequently right-side IE than patients without PE (33% vs. 17%). Patients with large-very large PE had a higher rate of systemic emboli (22% vs. 18%) and periannular abscess (22% vs 6%) than patients without PE. Renal failure (OR 2.1, 95%CI, 1.3-3.3) was associated with a higher risk for PE, while age (OR 0.98, 95%CI, 0.97-0.99) with a lower frequency of PE. One-year mortality of IE patients with large or very large PE was higher than that for small-moderate or absence of PE (56%, 18% and 24% respectively, p=0.033). Large-very large PE increases the one-year mortality of IE (OR 3.0, 95%CI, 1.2-7.9). In conclusion, renal failure and a younger age are associated with a higher risk of PE. Large-very large PE was associated with an increase in one-year mortality.
The American Journal of Cardiology 11/2013; 112(10). DOI:10.1016/j.amjcard.2013.07.024 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objetivos
El derrame pericárdico (DP) es una complicación (40–65%) que puede determinar taponamiento diferido letal. Determinamos la incidencia de DP grave en el postoperatorio de cirugía cardíaca.
Material y métodos
Estudio prospectivo de cohorte de pacientes consecutivos no seleccionados con intervenciones mayores de cirugía cardíaca. Se practicó estudio ecocardiográfico prealta. Se diagnosticó DP por criterios de Horowitz en modo M. Para la ecocardiografía-2D se consideraron diagnósticos de taponamiento cardíaco: colapso diastólico precoz del ventrículo derecho, compresión de cavidades cardíacas, plétora de vena cava inferior y variaciones superiores al 30% del flujo mitral. Con independencia de los estudios intraoperatorios o en cuidados intensivos, se programó estudio prealta a partir del séptimo día postoperatorio. Las ecocardiografías se practicaron en el laboratorio de ecocardiografía. Si la condición del paciente no lo permitió, el estudio se realizó en las unidades de hospitalización en los casos urgentes. Se usaron los ecógrafos Vivid i/Vivid 7 (General Electric, Fairfield, CT). Todos los estudios fueron supervisados por los ecocardiografistas expertos del servicio de cardiología.
De noviembre de 2009 – noviembre de 2011 se intervinieron 1.186 pacientes; 125 fueron trasladados precozmente a su hospital; 88 fallecieron sin estudio. De 973 pacientes, 53 (5,4%) presentaron DP grave o taponamiento por criterios clínicos/ecocardiográficos; 31/53 (58%) estaban asintomáticos. En 22/53 (42%) hubo sospecha clínica. Fueron reintervenidos 21 (40%). En 16 (30%) se administraron antiinflamatorios no esteroideos (AINE) y corticoides. La mortalidad fue 3,8% (2/53).
La ecocardiografía es una exploración inocua que permite el diagnóstico rápido de DP potencialmente letal, que tiene un componente medicolegal. Debe realizarse a todo postoperado de cirugía cardíaca.
[Show abstract][Hide abstract] ABSTRACT: Conventional antifungal therapy for fungal endocarditis has been associated with a poor cure rate. Therefore, combined medical
and surgical therapy has been recommended. However, new potent antifungal agents, such as echinocandins, could increase the
medical options and, in some cases, avoid the need for surgery. We report a case of Candida endocarditis treated successfully without valve replacement with intravenous liposomal amphotericin B (total dose, 4 g) and
intravenous caspofungin (a 100-mg loading dose followed by 50 mg per day for 8 weeks) as induction therapy and intravenous
caspofungin (100 mg 3 times per week for 12 weeks) as maintenance therapy.
[Show abstract][Hide abstract] ABSTRACT: Hepatopulmonary syndrome (HPS) has been defined as a clinical triad, including chronic liver disease, gas exchange defects (increased alveolar-arterial PO2 difference irrespective of the presence of arterial hypoxemia), and widespread intrapulmonary vascular dilatations. We determined the incidence and the clinical and pulmonary functional characteristics of HPS in candidates for orthotopic liver transplantation (OLT) and tested their predicted accuracy.
We studied 80 patients with cirrhosis prospectively, and carried out contrast-enhanced (CE) echocardiography and lung function tests, including ventilation-perfusion (V(A)/Q) distributions.
Fourteen patients had HPS (incidence, 17.5%). Patients with HPS (49 +/- 12 (+/-SD) years) had more cutaneous spiders, finger clubbing and dyspnea (P < 0.05 each) and a lower diffusing capacity (DLCO, 56 +/- 18% predicted; P < 0.001) than non-HPS patients (n = 66). Mild to moderate V(A)/Q inequalities and increased intrapulmonary shunt were predominant in HPS patients, but oxygen diffusion impairment was observed in those with hypoxemia (n = 8) only. The DLCO showed a considerable area under the receiver operating characteristic curve (0.89).
HPS in cirrhotic patient candidates for OLT shows a high incidence and these patients present with distinctive clinical and functional features compared with non-HPS individuals. The presence of a low DLCO may be of help for the diagnosis of HPS.
Journal of Hepatology 05/2001; 34(5):651-7. DOI:10.1016/S0168-8278(00)00108-2 · 11.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic excessive ethanol consumption exerts a deleterious effect on the myocardium. Although the effects of chronic alcoholism on systolic cardiac function are well known, diastolic involvement has been evaluated only partially. Therefore, we determined the presence of left ventricular diastolic impairment in chronic alcoholics and its relation with simultaneous systolic dysfunction. We also assessed the influence of ethanol consumption in diastolic impairment.
Thirty-five alcoholics with cardiomyopathy (ejection fraction < or = 50%) and 77 alcoholics with normal systolic function (ejection fraction > 50%) were evaluated. Assessment of New York Heart Association functional class, history of ethanol intake, technetium-99m radionuclide angiocardiography, and bidimensional Doppler echocardiography with evaluation of systolic and diastolic left ventricular function were performed.
Diastolic function impairment was present in one third of the alcoholics without cardiomyopathy, compared with two thirds of the patients with cardiomyopathy (p < 0.01). A pseudonormalization phenomenon of diastolic function was observed in patients with more advanced systolic dysfunction (ejection fraction < 32%). The deterioration of the diastolic parameters correlated with ethanol consumption, regardless of age (r = 0.44, p < 0.001 for ratio of peak velocity of the transmitral flow in early diastole and peak velocity of atrial contraction flow, with lifetime dose of ethanol).
There seems to be a dose-dependent effect of ethanol on systolic and diastolic heart function. Diastolic function impairment is present in one third of alcoholics with normal systolic function and is even more frequent when systolic dysfunction coexists.
Alcoholism Clinical and Experimental Research 01/2001; 24(12):1830-5. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mutations causing hypertrophic cardiomyopathy have been described in nine genes encoding sarcomeric proteins. We report a new mutation in three families, with a C-->G transversion in nucleotide 12 307 of the beta-myosin heavy chain gene, located at the essential light chain interacting region, resulting in the replacement of arginine by glycine at amino acid residue 723. PCR amplification of the selected regions followed by single strand conformation polymorphism analysis, DNA sequencing of the polymorphic patterns and restriction analysis were used to detect the mutation. A total of 23 individuals were diagnosed as carriers, and seven were obligate carriers or had been clinically diagnosed. The Arg723Gly mutation was associated with a malignant phenotype. Ten out of 30 affected members died suddenly or needed an implantable cardioverter-defibrillator at a mean age of 42, and seven members developed progressive heart failure, leading to death or heart transplant in five, at a mean age of 50 years. Echocardiography showed non-obstructive left ventricular hypertrophy in affected members older than 20 (sensitivity 68%). Mean survival of affected members was 51 years. In conclusion, a new mutation Arg723Gly in beta-myosin heavy chain gene is reported which shortens life expectancy because of sudden death and end-stage heart failure.
Journal of Molecular and Cellular Cardiology 12/2000; 32(12):2307-13. DOI:10.1006/jmcc.2000.1260 · 4.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A sympathetic overactivity has been reported in the early stages of essential hypertension and has been involved in the pathogenesis of left ventricular hypertrophy (LVH) in essential hypertension. The state of beta2-adrenergic receptors as related to the presence of this complication was investigated in a group of 15 essential hypertensive patients and compared to 10 normotensive control subjects. Left ventricular mass index was determined by bidimensional echocardiography. Plasma catecholamine levels were measured by a radioenzymatic assay. beta2-adrenoceptor density was measured in intact lymphocytes by radioligand binding assay, using the hydrophilic ligand CGP 12177. beta2- adrenoceptor function was assessed by measuring intracellular cAMP levels in isoproterenol-stimulated lymphocytes. Left ventricular mass index (P < 0.05), body mass index (P < 0.01), plasma noradrenaline levels (P < 0.05) and beta2-adrenoceptor density (P < 0.05) were higher in hypertensives than in controls. Left ventricular mass index correlated with body mass index both in normotensives and hypertensives, as well as with plasma noradrenaline levels only in normotensives. Left ventricular mass index also showed a positive correlation with mean arterial pressure and an inverse relationship with beta2-adrenoceptor density and response only in hypertensive patients. In conclusion, left ventricular hypertrophy in young essential hypertensives is associated to a reduced beta2-adrenoceptor density and function, probably as a compensating mechanism of the hypertrophied myocardiocyte secondary to the increased sympathetic outflow. Journal of Human Hypertension (2000) 14, 17-21.
Journal of Human Hypertension 02/2000; 14(1):17-21. DOI:10.1038/sj.jhh.1000927 · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A functional genetic variant consisting of a C825T substitution in the GNB3 gene, encoding for the G-protein beta(3) subunit, has been associated with enhanced G-protein activation and cell growth. The aim of the study was to investigate the association of this polymorphism with left ventricular hypertrophy (LVH) in a sample of patients with essential hypertension. Left ventricular mass was assessed by 2-mode echocardiography in 86 patients with essential hypertension, and GNB3 C825T genotype was determined by polymerase chain reaction and restriction digestion. Thirty-seven (0.43) patients were homozygous for the C allele (CC), 40 (0.47) were heterozygous (CT), and 9 (0.10) were homozygous for the T allele (TT). The genotype distribution among the patients was in Hardy-Weinberg equilibrium. Values of left ventricular end-diastolic diameter (52.0+/-0.7 versus 48.9+/-0.9 mm, P=0.007), posterior wall thickness (11.3+/-0.2 versus 10.6+/-0.2 mm, P=0.042), and left ventricular mass index (152.7+/-4.4 versus 135.2+/-6.4 g/m(2), P=0. 023) were significantly higher in patients with CT and TT genotypes considered together (CT+TT) than in CC patients. The distribution of the genotypes was significantly different when comparing patients with LVH: 20 (0.33) CC and 40 (0.67) CT+TT patients had this complication, and 17 (0.65) CC and 9 (0.35) CT+TT patients did not (P<0.01). The frequency of the T allele was significantly different among patients with (0.40) and without (0.20) LVH (P<0.01). A logistic regression analysis showed that the association between the T allele and LVH was independent of age, mean blood pressure, body mass index, and alcohol consumption. The relative risk of LVH in patients bearing the T allele (CT+TT group) compared with CC hypertensive patients was 3.03 (95% CI 1.14 to 8.05). The findings suggest an association between LVH and the 825T allele in hypertensive patients.
[Show abstract][Hide abstract] ABSTRACT: The possible association between the insertion/deletion (I/D) polymorphism of the angiotensin I converting enzyme (ACE) gene and left ventricular hypertrophy (LVH) was investigated in a group of essential hypertensive patients. Seventy-one essential hypertensive patients (35 men and 36 women), aged 51 +/- 1 years, were genotyped by PCR for the I/D polymorphism of the ACE gene. Cardiac morphology and function were assessed by means of M-mode echocardiography. The relative frequencies of the three genotypes, DD, DI, and II, were respectively: 24%, 55%, and 21%. Mean values of left ventricular mass index were 145, 144, and 150 g/m2 for DD, DI, and II genotypes, without significant differences among them (P = 0.82). Likewise, the prevalence of LVH (76%, 64%, and 87%) was not significantly different among the three genotypes (P = 0.23). We conclude that the ACE gene I/D polymorphism is not associated with LVH in essential hypertension. Journal of Human Hypertension (2000) 14, 47-49.
Journal of Human Hypertension 02/2000; 14(1):47-9. DOI:10.1038/sj.jhh.1000941 · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of the present study was to evaluate clinical correlates of silent cerebral white matter lesions (WML) in asymptomatic middle-aged untreated essential hypertensive patients. Fifty four mild to moderate never treated essential hypertensive patients (34 men, 20 women), aged 50–60 years (mean age 54 ±4), without clinical evidence of target organ damage were studied. All patients underwent brain-magnetic resonance imaging, 24-h ambulatory blood pressure monitoring, echocardiography, and blood and urine analyses. Twenty-two (40%) hypertensives were found to have WML. Patients with WML have significantly higher values of both office and 24-hour systolic blood pressure (SBP) and pulse pressure (PP), whereas diastolic blood pressure (DBP) were not significantly different between groups. Furthermore, hypertensives with WML exhibited significantly lower values of glomerular filtrate rate, measured as creatinine clearance (CC), and a significantly higher left ventricular mass index (LVMI). (See Table)These results suggest that SBP, and PP may be associated with the development of cerebral WML. The presence of WML in asymptomatic middle-aged hypertensives patients is associated with the existence of target organ damage at other levels, such as renal and cardiac impairment.
[Show abstract][Hide abstract] ABSTRACT: In the past, valve homografts have been used in the treatment of aortic endocarditis. This report details our experience in tricuspid valve replacement using cryopreserved mitral homografts in HIV-positive drug addicts with infective endocarditis.
Five HIV-1-infected drug addicts with active uncontrollable tricuspid valve endocarditis underwent tricuspid valve replacement with a cryopreserved mitral homograft.
There was no early mortality, and median follow up was 5 years (range: 1 to 6 years). One late mortality occurred as a result of heroin overdose. Three of the five patients developed six episodes of recurrent bacterial tricuspid endocarditis on the homograft; these were cured successfully with antibiotics. All survivors remain in NYHA functional class I. The latest transthoracic echocardiography examination showed mild, moderate or severe regurgitation in one, two and two patients, respectively. To date, neither homograft calcification nor rupture of the papillary muscle has been detected.
This novel technique is considered to be an adequate approach to these cases of uncontrollable infectious disease. Further episodes of valvular infection can be managed medically.
The Journal of heart valve disease 10/1999; 8(5):575-7. · 0.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Immunosuppression caused by human immunodeficiency virus 1 (HIV) infection appears to modify the clinical characteristics and to increase the severity of several bacterial infections. The impact of HIV infection and the degree of immunosuppression on the clinical characteristics and outcome of infective endocarditis (IE) in intravenous (IV) drug users has not been well characterized.
Prospective cohort study among 292 consecutive IV drug users with IE diagnosed in 2 academic institutional hospitals in Barcelona, Spain, from January 1, 1984, to October 31, 1995. Serostatus of HIV infection was documented in 283 patients. We measured demographics, clinical and biological data, cause, echocardiographic findings, HIV serostatus and classification, CD4 cell count, complications, and mortality.
Among the 283 episodes of IE, 216 (76.3%) were in HIV-infected patients and 67 (23.7%) in non-HIV-infected patients. Rate of IE per 1000 admissions ranged from 0.17 to 0.82 per year, peaking in 1989. Characteristics of IE independently associated with HIV infection were right-side involvement (odds ratio [OR], 7.6; 95% confidence interval [CI], 3.5-16.7), a micro-organism different from viridans streptococci (OR, 2.5; 95% CI, 1.1-5.9), duration of drug abuse longer than 5 years (OR, 5.0; 95% CI, 2.4-10.3), and white blood cell count of no more than 10 X 10(9)/L (OR, 2.2; 95% CI, 1.1-4.2). There were no significant differences in mortality due to IE according to HIV serostatus. Among the 216 patients with HIV infection, the variables independently associated with worse outcome were CD4 cell count lower than 0.200 x 10(9)/L and left-sided or mixed IE.
Although there is a difference in clinical presentation in IE in IV drug users, outcome was similar according to their HIV status. However, among HIV-infected patients, severe immunosuppression and mixed or left-side valvular involvement were strong risk factors for mortality.
Archives of Internal Medicine 11/1998; 158(18):2043-50. DOI:10.1001/archinte.158.18.2043 · 17.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the prognostic value of dipyridamole stress echocardiography in survivors of a first uncomplicated acute myocardial infarction.
A total of 75 patients (68 men, 7 women) aged 58 years (range, 37-77) were studied 3-5 days after a first acute myocardial infarction and followed up for a mean of 10 months. Dipyridamole infusion was administered at high doses: 0.56 mg/kg, adding 0.28 mg/kg if the test was still negative. Two-dimensional echocardiography was continuously recorded during infusion and the test was considered positive if a decrease in regional contractile function appeared and negative if no assynergy was observed up to 15 min after the beginning of dipyridamole administration. A wall motion score index of regional function was derived by summation of individual segment scores divided by the number of interpreted segments. This was calculated for rest and peak dipyridamole echocardiograms. Fifty of 75 patients underwent coronary angiography based on clinical criteria.
There were 31 coronary events: 4 deaths, one reinfarction, 13 angina. Thirteen patients underwent coronary revascularization (9 bypass and 4 angioplasty). Dipyridamole echocardiography was positive in 29 patients (39%) and negative in 46 patients (61%). Twenty patients (69%) presented coronary events in the group of positive test versus only 11 (24%) of negatives (p = 0.0001). Four patients died in the positive group while none in the negative group. Sensitivity, specificity and accuracy for all cardiac events were 65, 80 and 73%, respectively. Significant variables from univariate analysis were dipyridamole stress echocardiography response, wall motion score index at peak dipyridamole, ischemic changes in ECG and treatment with two or more antianginal drugs. Multivariate analysis showed positive dipyridamole echocardiography as the only independent prognostic factor to predict cardiac events in postmyocardial infarction patients (RR = 2.56; 95% CI = 1.12-5.84). Four of 19 patients with one vessel disease and 17 of 22 patients with 2-3 vessel disease presented a positive dipyridamole test; whereas the test was negative in the remaining nine patients with normal coronary angiography.
Dipyridamole stress echocardiography is a safe and feasible pharmacologic stress imaging method to stratify postmyocardial infarction patients at risk of cardiovascular events.
[Show abstract][Hide abstract] ABSTRACT: We report the case of a 45 year-old woman with systemic lupus erythematosus (SLE), who developed clinical and echocardiographic signs of hypertrophic cardiomyopathy. Neither a family history of cardiomyopathy or sudden death nor a personal history of hypertension or valvular lesions were present. The association of SLE with hypertrophic cardiomyopathy has been previously described in only 2 patients.
[Show abstract][Hide abstract] ABSTRACT: To compare the prevalence and cardiac status of male and female alcoholics with alcoholic cardiomyopathy during a 5-year period, all chronic alcoholics with dilated cardiomyopathy who had clinical symptoms of heart failure were included. Alcoholic cardiomyopathy was diagnosed in 10 chronic alcoholic women and in 26 men; the prevalence of alcoholic cardiomyopathy was similar in both sexes. No significant differences were observed in age, nutritional parameters, and clinical and radiologic data of heart failure between the 2 groups. Alcoholic women reported a significantly lower daily dose of ethanol (p = 0.002), a shorter duration of alcoholism (p = 0.017), and a lower total lifetime dose of ethanol consumption (p = 0.001), and had a lower New York Heart Association functional class than men. Women also had lesser ventricular dysfunction than men. In a multivariate analysis, left ventricular systolic dysfunction was related to the total lifetime dose of ethanol consumption (p <0.04), but not to gender. Finally, when patients were matched for left ventricular ejection fraction, women had consumed a lower total lifetime dose of ethanol than men (p <0.001). The prevalence of alcoholic women with dilated cardiomyopathy was found to be similar to that of alcoholic men, although women required a lower total lifetime dose of ethanol to develop the disease.
The American Journal of Cardiology 08/1997; 80(4):481-5. DOI:10.1016/S0002-9149(97)00399-8 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Clinical, biochemical and echocardiographic characteristics were evaluated from 50 essential hypertensive patients classified asccording to their salt-sensitivity status. Salt-sensitive hypertension was diagnosed by means of ambulatory blood pressure monitoring (ABPM) in 22 (44%) patients showing a significant increase in mean BP (P < 0.05) from a 7-day period of low salt (20 mmol NaCl/day) intake, to a 7-day period of high salt (260 mmol NaCl/day) intake. The remaining 28 (56%) patients were considered as having salt-resistant hypertension. Compared with salt-resistant patients, salt-sensitive ones showed an increased left ventricular mass index (P = 0.0118), septal (P = 0.0021) and posterior wall thickness (P = 0.0026), without differences in the internal diastolic diameter. Decreased values of HDL-cholesterol (P = 0.0475) and increased total cholesterol/HDL-cholesterol ratio (P = 0.0098) were also observed in the salt-sensitive, compared with the salt-resistant hypertensive patients. Age, gender, body mass index, systolic and diastolic BP, fasting plasma glucose, creatinine and uric acid did not differ between salt-sensitive and salt-resistant patients. We conclude that, at the same level of BP, salt-sensitive patients exhibit an increased prevalence of left ventricular hypertrophy and a worse lipid profile. These two aspects may confer to salt-sensitive patients an increased risk in terms of cardiovascular morbidity and mortality.
Journal of Human Hypertension 12/1996; 10(12):795-9. · 2.70 Impact Factor