Clostridium septicum-infected aortic aneurysm or graft is a deadly diagnosis

BackgroundClostridium septicum is an anaerobic, motile, spore-forming, toxin-producing gram-positive bacillus that can lead to rapidly progressive gas gangrene due to the release of alpha toxin. Aortic aneurysm secondary to C. septicum infection is a rare condition with 60 cases reported in the literature; however, we have recently treated several patients with the condition in our large tertiary care and aortic center.MethodsBlood and tissue culture results collected between January 2005 and January 2018 and maintained in the microbiology laboratory database at the Cleveland Clinic were reviewed to identify those with C. septicum reported. Each was reviewed to determine radiographic or histopathologic correlation with aortic disease.ResultsSeven cases of C. septicum aortitis were reviewed. Underlying malignant disease was found in four cases and a history of remote malignant disease in one case. The most common location for infection was the infrarenal abdominal aorta. Vascular surgery had previously been performed in three of the cases. Five of the seven patients underwent operative repair. All patients were treated with β-lactam antibiotics. The two patients who did not undergo an operation died, which is consistent with the 100% mortality described in the literature. Of the five patients who underwent an operation, there was only one documented survivor and one was lost to follow-up.ConclusionsIn the largest reported case series, only a small percentage of patients with C. septicum-infected aortic aneurysms survived >1 year. In the patients described, those who did not receive an operation had 100% mortality. Earlier recognition and prompt operation with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.     

Guía anestésico-quirúrgica en el tratamiento de la cirugía de aorta ascendente y del arco aórtico. Documento de consenso de la Sociedad Española de Cirugía Cardiovascular y Endovascular y la Sociedad Española de Anestesiología,Reanimación y Terapeútica del Dolor

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving “Aortic teams” made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of “AORTIC TEAM”(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.     

Immediate and 1-year success rate of type 2 endoleak treatment using three-dimensional image fusion guidance

PurposeTo retrospectively assess immediate and 1-year success rate of type 2 endoleak (T2E) treatment with ethylene-vinyl-alcohol-polymer using three-dimensional (3D) image fusion guidance with cone beam computed tomography via trans-arterial embolization (TAE) or direct percutaneous sac injection (DPSI).Materials and methodsA total of 37 patients with T2E who were treated either using TAE (34/37; 92%) or DPSI (9/37; 8%) were included. There were 34 men and 3 women with a mean age of 86 ± 9 (SD) years (range: 67–104 years). Mean aneurysm diameter was 67 ± 14 (SD) mm (range: 42–101 mm) at pre-procedure evaluation. Immediate success was complete embolization of the sac and feeding artery. 1-year success was reduction or stability of the aneurysmal sac diameter based on pre-procedure and 12-month follow-up examinations. Safety (treatment-related complications), patient demographics, duration of procedure and contrast volume were reported.ResultsImmediate and 1-year successful outcomes were reported in 94% (n = 32) and 88% (n = 28) of patients after TAE and 100% (n = 9) and 89% (n = 8) after DPSI. T2E treatments were immediately successful for 95% of the procedures (41/43) and for 88% (36/41) at 1 year. Overall, T2E treatment was effective in 33 patients (89%). No major complications occurred. Mean procedure time and contrast volume were significantly different between the 2 techniques with respectively 87 ± 16 (SD) min (range: 65–120 min) and 75 ± 26 (SD) mL (range: 40–130 mL) for TAE and 32 ± 10 (SD) min (range: 20–50 min) (P < 0.01) and 6 ± 6 (SD) mL (range: 2–22 mL) (P < 0.01) for DPSI. Mean aneurysm diameter at 1-year was 68 ± 17 (SD) mm (range: 43–101 mm). No significant differences in the pre-procedure sac diameter were found at long-term follow-up between patients without T2E and those with persistent T2E (P = 0.1) in the successful embolization group (n = 33).ConclusionTAE or DPSI treatments of T2E with ethylene-vinyl-alcohol-polymer using 3D-image fusion guidance were immediately successful for 95% of the procedures and remained effective for 88%. Longer follow-up is necessary to assess sac stability in the case of persistent endoleak.     

Infective endocarditis in patients who have undergone transcatheter aortic valve implantation: a review

BackgroundTranscatheter aortic valve implantation (TAVI) has been approved for the treatment of severe aortic stenosis since 2008 and recent trials have shown that TAVI is at least non-inferior to surgical aortic valve replacement (SAVR) with regards to short-term efficacy and safety in patients across all surgical risk profiles. Prosthetic valve endocarditis of the transcatheter heart valve is a feared complication; data on the risk of infective endocarditis (IE) subsequent to TAVI are now gradually emerging.ObjectivesWe set forth to conduct a review of the incidence, diagnosis, microbial aetiologies, prevention, outcome and management of TAVI-IE.SourcesFrom the MEDLINE database we included a total of 12 observational studies and five studies of long-term results from randomized controlled trials.ContentThe incidence of TAVI-IE was reported to be between 0.7% and 3.0% per person-year. The most common microbes were reported to be enterococci, Staphylococcus aureus, streptococci and coagulase-negative staphylococci. International guidelines on prevention strategies of IE recommend good sanitary conditions including cutaneous care, good oral hygiene and good care of dialysis catheters. Antibiotic prophylaxis is recommended by guidelines prior to dental procedures in patients with TAVI; however, evidence is sparse. The majority of the patients included in this review with TAVI-IE had an indication for surgical intervention due to IE (50.0% or more); however, only a small subset of the patients underwent surgery (16.4% or less). The in-hospital mortality was around 25%, i.e. of the same order of magnitude as in prosthetic valve IE in general, but varied substantially between studies (from 11% to 64%).ImplicationsThe US Food and Drug Administration's approval of TAVI in patients at low surgical risk may change the characteristics of patients with TAVI, which may influence the incidence, management, and outcome of patients with TAVI-IE.     

Effects of continuous positive airway pressure treatment on aortic stiffness in patients with resistant hypertension and obstructive sleep apnea: A randomized controlled trial

Resistant hypertension (RHT) is associated with obstructive sleep apnea (OSA) and increased aortic stiffness, measured by carotid‐femoral pulse wave velocity (cf‐PWV). We aimed to evaluate in a randomized controlled trial, the effect of Continuous positive airway pressure (CPAP) treatment on cf‐PWV in comparison with a control group in patients with RHT and moderate‐severe OSA. One‐hundred and sixteen patients were randomized to 6‐month CPAP treatment (56 patients) or no therapy (60 patients), while keeping their antihypertensive treatment unchanged. Carotid‐femoral pulse wave velocity was performed at the beginning and end of the 6‐month period. Intention‐to‐treat intergroup differences in cf‐PWV changes were assessed by a generalized mixed‐effects model with the allocation group as a fixed factor and adjusted for age, sex, changes in mean arterial pressure and the baseline cf‐PWV values. Subgroup sensitivity analyses were performed, excluding patients with low CPAP adherence and low cf‐PWV at baseline. CPAP and control groups had similar clinic‐laboratorial characteristics. Patients had a mean cf‐PWV of 9.4 ± 1.6 m/s and 33% presented cf‐PWV > 10 m/s. During treatment, the control group had a mean increase in cf‐PWV of +0.43 m/s (95% confidence interval [CI], +0.14 to +0.73 m/s; p = .005), whereas the CPAP group had a mean increase of +0.03 m/s (95% CI, ?0.33 to +0.39 m/s; p = .87), resulting in a mean difference in changes between CPAP and control of ?0.40 m/s (95% CI, ?0.82 to +0.02 m/s; p = .059). Subgroup analyses did not change the results. In conclusion, a 6‐month CPAP treatment did not reduce aortic stiffness, measured by cf‐PWV, in patients with RHT and moderate/severe OSA, but treatment may prevent its progression, in contrast to no‐CPAP therapy.     

The difficult balance between thrombosis and bleeding after transcatheter aortic valve replacement: A translational review

The difficult balance between thrombosis and bleeding after transcatheter aortic valve replacement. TAVR: transcatheter aortic valve replacement.