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Background: Abnormal papillary muscles (PM) are often found in hypertrophic cardiomyopathy )HCM). Objective: To assess the relationship between morphological alterations of PM in patients with HCM and left ventricular outflow tract )LVOT) obstruction, using magnetic resonance imaging (MGI) and echocardiography. Methods: Fifty-six patients with HCM (mean age 42 years )interquartile range 27, 51), 70% male) and 30 controls (mean age (42 (30, 53) years, 80% male) underwent MRI on a 1.5 T scanner (Siemens, Erlangen, Germany). Standard cine images were obtained in shortaxis (base to apex), along with two-, three- and four- chamber views. The presence of bifid PM (none, one or both) and anteroapical displacement of anterolateral PM was recorded by MRI and correlated with resting LVOT gradients obtained by echocardiography. Results: Double bifid PM (70% vs 17%) and anteroapical displacement of anterolateral PM (77% vs 17%) were more prevalent in patients with HCM than in controls (p<0.001). Subjects with anteroapically displaced PM and double bifid PM had higher resting LVOT gradients than controls (45 )6, 81) vs 12(0, 12) mm Hg (p<0.01) and 42)6, 64) vs 11(0, 17) mm Hg (p = 0.02), respectively. In patients with HCM, the odds ratio of having significant ) 30 mm Hg) peak resting gradient was 7.1 (95% Cl 1.4 to 36.7) for anteroapically displaced anterolateral PM and 10.4 )95% Cl 1.2 to 91.2) for double bifid PM (both p = 0.005), independent of septal thickness, use of 3-blockers and/or calcium blockers and resting heart rate. Conclusions: Patients with HCM with abnormal PM have a higher degree of resting LVOT gradient, which is independent of septal thickness. [ABSTRACT FROM AUTHOR]

Mitral valve endocarditis typically results in mitral regurgitation. However, endocarditis leading to functional mitral stenosis is uncommon and, when present, fungal organisms are typically implicated. Thus, obstructive-type bacterial endocarditis due to large vegetations blocking the mitral valve orifice is a rare occurrence, with approximately 20 reported cases in the literature. We report on two patients with bacterial endocarditis and severe functional mitral stenosis requiring emergent surgery. Additionally, this is the first report of vancomycin-resistant enterococcus causing endocarditis and functional mitral stenosis. The discussion emphasizes the hemodynamic instability of these patients and need for early surgical intervention. [ABSTRACT FROM AUTHOR]

Background. Invasive aspergillosis (IA) is associated with significant morbidity and mortality in solid organ transplant recipients but data on the incidence rates stratified by type of solid organ are limited. Objective. To describe the attack rates and incidence of IA in solid organ transplant recipients, and the impact of universal Aspergillus prophylaxis (aerosolized amphotericin B or oral itraconazole) in lung transplant recipients. Patients. The 2046 patients who received solid organ transplants at the Cleveland Clinic Foundation from January 1990 through 1999 were studied. Methods. Cases were ascertained through computerized records of microbiology, cytology, and pathology reports. Definite IA was defined as a positive culture and pathology showing septate hyphae. Probable IA was clinical disease and either a positive culture or histopathology. Disseminated IA was defined as involvement of two or more noncontiguous anatomic sites. Results. We identified 33 cases of IA (28% disseminated) in 2046 patients (attack rate = 1.6%) for an incidence of 4.8 cases per 1000 patient-years (33 cases/6813 pt-years). Both the attack and the incidence rates were significantly higher for lung transplant recipients vs. other transplant recipients: lung 12.8% (24 cases/188 patients) or 40.5 cases/1000-pt year vs. heart 0.4% (3/686) or 1.4 per 1000-pt year vs. liver 0.7% (3/439) or 2.1 per 1000-pt year vs. renal 0.4% (3/733) or 1.2 per 1000-pt year (P < 0.01). The incidence of IA was highest during the first year after transplantation for all categories, but cases occurred after the first year of transplantation only in lung transplant recipients. The attack rate of IA in lung transplant recipients was significantly lower after institution of routine Aspergillus prophylaxis (4.9% vs. 18.2%, P < 0.05). Conclusions. The highest incidence and attack rate of invasive aspergillosis among solid organ transplant recipients occurs in lung transplant recipients and supports the... [ABSTRACT FROM AUTHOR]

Background: The recent development of powerful agents such as mycophenolate mofetil and tacrolimus has altered current regimens for the prevention and treatment of allograft rejection. Questions have been raised about these newer regimens in terms of susceptibility to opportunistic infections and effects on host defenses. Severe hypogammaglobulinemia has been infrequently described in solid organ transplant recipients, but has been recently noted in six heart transplant recipients at one center, of whom five were receiving a combination of tacrolimus, mycophenolate mofetil, and prednisone. Methods: Case summaries of six recent heart transplant recipients with total immunoglobulin G (IgG) levels of less than 310 mg/dl, five of whom had cytomegalovirus (CMV) infection and three of whom had multiple infections including Nocardia, invasive Trichophyton, and Acinetobacter bacteremia. Previous literature was reviewed with the aid of a Medline search using the search terms hypogammaglobulinemia; kidney, liver, heart, lung, and organ transplantation; mycophenolate mofetil; tacrolimus; cyclosporine; azathioprine; and nocardiosis. Results: We here report six cardiac transplant recipients seen over a period of one year who were found to have immunoglobulin G levels of 310 mg/dl or below (normal: 717–1400 mg/dl). The first five patients were diagnosed because of evaluation for infections; the sixth, who was asymptomatic with an IgG level of 175, was found during screening for hypogammaglobulinemia instituted as a result of these first five patients. All six patients had received steroid pulses for rejection; all received mycophenolate mofetil; and 5/6 had been switched from cyclosporine to tacrolimus because of steroid-resistant rejection. Transient neutropenia (absolute neutrophil count less than 1000) was observed in 2/6; 3/6 had received OKT3 therapy for refractory rejection. These six patients were treated with a combination of antimicrobials, immunoglobulin replacement, and decrease in immunosuppressive therapy. Conclusions: The finding of unexpected hypogammaglobulinemia and concomitant infectious complications in six heart transplant recipients highlights a possible complication in a subset of patients receiving newer immunosuppressive agents. A larger prospective study is underway to determine risk factors for development of post-transplant hypogammaglobulinemia and to assess pre-transplant immune status of these recipients. Monitoring of immunoglobulin levels in high-risk patients receiving intensified immunosuppressive therapy for rejection may help to prevent infectious complications. [ABSTRACT FROM AUTHOR]

Objective: To determine why and how sedatives and analgesics are ordered and administered during the withholding and withdrawal of life support from critically ill patients.Design: Prospective case series.Setting: Medical-surgical intensive care units at a county hospital and a university hospital.Patients: Consecutive 1-year sample of 22 patients from whom life support was withheld or withdrawn in one intensive care unit at a county hospital and a random sample of 22 similar patients in the intensive care unit in the university hospital over the same period.Main Outcome Measures: Physicians and nurses were interviewed to determine their reasons for ordering and administering drugs, and medical records were reviewed to document amounts of drugs ordered and administered.Results: Drugs were given to 75% of patients during withholding and withdrawal of life support. Patients who did not receive medication were comatose and considered incapable of benefiting from sedation and analgesia. The median time until death following the initiation of the withholding or withdrawal of life support was 3.5 hours in the patients who received drugs and 1.3 hours in those patients who did not (P, not significant). Physicians ordered drugs to decrease pain in 88% of patients, to decrease anxiety in 85%, to decrease air hunger in 76%, to comfort families in 82%, and to hasten death in 39%; in no instance was hastening death the only reason cited. The amounts of benzodiazepines and opiates averaged 2.2 mg/h of diazepam and 3.3 mg/h of morphine sulfate in the 24 hours before withholding and withdrawal of life support and 9.8 mg/h and 11.2 mg/h in the 24 hours thereafter (P less than .025 and P less than .001, respectively).Conclusions: Large doses of sedatives and analgesics were ordered primarily to relieve pain and suffering during the withholding and withdrawal of life support, and death was not hastened by drug administration. [ABSTRACT FROM AUTHOR]

Background: The AlloMap gene expression test is used for the non-invasive detection of rejection. However, the impact of early post-transplant ischemic injury on subsequent AlloMap gene expression analysis has not been evaluated before. Methods: Sixty seven heart transplant recipients, mean age 53 years, were evaluated at a mean 34 months post-transplant. AlloMap score was determined on the same day of heart biopsies. Nineteen patients had evidence of early post-transplant ischemic injury (Injury group). These were compared with the remaining 48 patients, Control group. Results: Using multiple regression model with a backward selection method, post-transplant ischemic injury was found to be associated with significant increased AlloMap score compared with controls (31.5 ± 4.6 vs. 26 ± 6.2, p < 0.001). The Injury group had increased transplant vasculopathy (KM 5-year freedom from vasculopathy: 34% vs. 52%, p = 0.015), than Controls. Conclusions: Post-transplant ischemic injury is associated with up-regulated AlloMap gene expression, and hence, may provide another explanation for a high score in the absence of rejection. [ABSTRACT FROM AUTHOR]

Background: Patients with hypertrophic cardiomyopathy (HCM) exhibit a difference in left ventricular outflow tract (LVOT) obstruction, independently of basal septal thickness (BST). Some patients with HCM have a steeper left ventricle to aortic root angle than controls. Objective: To test the predictors of the LV-aortic root angle and the association between LV-aortic root angle and LVOT obstruction using three-dimensional imaging. Patients: 153 consecutive patients with HCM (mean (SD) age 46 (14) years, 68% men) and 62 patients with hypertensive heart disease of the elderly (all >65 years of age, 73 (6) years, 34% men) who underwent whole-heart three-dimensional cardiac magnetic resonance (CMR) angiography (1.5 T) and Doppler echocardiography. Forty-two controls (age 43 (11) years, 38% men) who underwent contrast-enhanced multidetector computed tomography and were free of cardiovascular pathology were also studied. Main outcomes: LV-aortic root angle, BST and maximal non-exercise LVOT gradient were measured in patients with HCM and in hypertensive-elderly patients. Additionally, LV-aortic root angle and BST were measured in controls. Results: The mean (SD) LV-aortic root angle was significantly different (p<0.001) in the three groups: HCM (134 (10)°), hypertensive-elderly (128 (10)°), control (140 (7)°). There was an inverse correlation between age and LV-aortic root angle in the three groups (all p<0.001): HCM (r=-0.56), hypertensive-elderly (r=-0.35), control (r=-0.48). On univariate analysis, in the HCM group, LV-aortic root angle (β=-0.34, p<0.001), age (β=0.23, p=0.01) and end-systolic volume index (β=-0.20, p=0.02), but not BST (β=0.02, p=0.8), were associated with LVOT gradient. On multivariate analysis, only LV-aortic root angle was associated with LVOT gradient. Conclusions: Patients with HCM have a steeper LV-aortic root angle than controls. In patients with HCM, a steeper LV-aortic root angle predicts dynamic LVOT obstruction, independently of BST. [ABSTRACT FROM AUTHOR]