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The clinical profiles of infective endocarditis (IE) might have changed in recent years, owing to the advent of transesophageal echocardiography, the introduction of new diagnostic criteria, and the increased frequency of intravenous drug abuse. In this retrospective study, we sought to identify factors affecting the in-hospital outcome of IE patients in a single tertiary referral center in the 1990s (1990-1997). Eighty-eight episodes of IE in 80 consecutive patients admitted from January 1990 through June 1997 were evaluated. Clinical variables that were significantly associated with in-hospital mortality in univariate analyses were entered into a multiple logistic regression model. A total of 22 patients (25%) died. Fatal episodes were significantly more likely than non-fatal episodes to involve older patients (or = 50 years), use of coumadin, short interval between symptom onset and hospitalization (15 days), noncardiac shock, and complications of the heart, central nervous system, and kidneys. White blood cell counts and C-reactive protein concentrations were also significantly higher in fatal than in non-fatal episodes of IE. Multivariate analysis showed that in-hospital mortality was associated with noncardiac shock, neurological complications, cardiac complications, and older age (or = 50 years). Compared with previous reports, our findings suggest that the clinical profiles of IE have undergone some changes in the 1990s. The most important prognostic predictors of in-hospital mortality in patients with IE were noncardiac shock and neurologic complications.

Short Doppler-derived mitral deceleration time of early filling has been proved to be an independent predictor of poor prognosis in patients with left ventricular dysfunction. However, the prognostic value of Doppler-derived mitral deceleration time in postinfarction patients without overt left ventricular dysfunction is poorly understood. A total of 27 survivors of acute myocardial infarction with left ventricular ejection fractions of 35% or more, as determined by radionuclide ventriculography, were prospectively studied. Doppler study was performed 5 to 7 days after the index infarction. The patients were divided into two groups. Group A included 10 patients whose mitral deceleration time was 125 msec or less and group B consisted of 17 patients whose mitral deceleration time was 125 msec or more. The two groups were similar in terms of age and gender distribution and there were no statistically significant differences in coronary risk factors, peak creatine kinase concentration, location of infarction, Killip classification, thrombolytic therapy, left ventricular ejection fraction, or medications. After a mean follow-up period of 30 months, the rate of congestive heart failure (New York Heart Association, NYHA, class II or above) was significantly higher in group A (5/10) than in group B (1/17) (p0.01). These results suggest that a short mitral deceleration time could be a useful early predictor of the potential development of future congestive heart failure in postinfarction patients with left ventricular ejection fractions of 35% or more.

Pulmonary embolism can be a catastrophic event leading to early death or serious hemodynamic instability. Thrombolytic therapy, in addition to heparin therapy, may improve the clinical condition and reduce the chance of recurrent pulmonary embolism in some cases. However, the acceptable "time window" for thrombolytic therapy is not well documented, though it has been used successfully as late as 14 days after pulmonary embolism. Successful delayed thrombolytic therapy beyond this "time window" in patients with massive pulmonary embolism has not been reported. We report a case of massive pulmonary embolism in which thrombolytic therapy was delayed more than 1 month after symptom onset. A 56-year-old woman was taken to National Cheng Kung University Hospital because of an episode of recurrent syncope, followed by progressive shortness of breath of 1 month's duration. Hypoxemia and hemodynamic instability were noted on admission. Echocardiography and a lung perfusion scan provided strong evidence of pulmonary embolism. Subsequent pulmonary angiography confirmed the diagnosis of multiple pulmonary emboli. The patient received a standard dose of intravenous tissue plasminogen activator 7 days after admission because of persistent symptoms and hypoxemia. Her clinical condition dramatically improved after treatment. Follow-up imaging studies showed resolution of the emboli. She was discharged in good condition. This case suggests that delayed thrombolytic therapy in patients with massive pulmonary embolism can still be beneficial in selected cases, even if given more than 2 weeks after symptom onset.

A prospective study was designed to investigate potential changes of left atrial (LA) spontaneous echo contrast with time and the effects of antithrombotic therapy on its presence in 77 patients with chronic nonrheumatic atrial fibrillation (AF), using serial transesophageal echocardiography (TEE). During a mean follow-up period of 20 +/- 15 months (range 6 to 77), a total of 197 TEE studies were performed in these patients. Baseline TEE revealed that LA spontaneous echo contrast was absent in 43 patients (group 1) and present in 34 (group 2). LA thrombus was found in 8 of group 2 but in none of the group 1 patients. During the follow-up period, only 2 of the group 1 patients were receiving antithrombotic agents; the patients in group 2 without LA thrombus were treated with either warfarin or aspirin, whereas those with LA thrombus were treated with warfarin. On the latest TEE study, LA spontaneous echo contrast was observed in 19 of the group 1 patients (44%) and was persistently found in all of the group 2 patients. During the study period, no patient was found to develop new LA thrombus formation and only 4 episodes of transient ischemic attack were recorded in 4 patients (embolic event rate = 3.1% per year). Of these, 2 were observed in group 1 and the remaining 2 were from group 2 and under aspirin therapy (event rate = 2.2% and 4.7% per year, respectively). In the subgroup of patients with LA thrombus receiving warfarin therapy, follow-up TEE revealed complete resolution of the thrombi in 6 and partial resolution in the remaining 2 in spite of the persistence of LA spontaneous echo contrast; none of these patients developed clinical thromboembolic events during the study period. Thus, future occurrence of LA spontaneous echo contrast could be observed by serial TEE at a substantial rate in patients with nonrheumatic AF who have no LA spontaneous echo contrast; follow-up TEE should be recommended for these patients to detect early the potential occurrence of LA spontaneous echo contrast if preventive antithrombotic therapy is not considered. Although warfarin therapy is associated with resolution of LA thrombus, neither warfarin nor aspirin is effective for suppressing the presence of LA spontaneous echo contrast in nonrheumatic AF.

The dipyridamole thallium-201 single photon emission computed tomography (SPECT) and resting gated blood pool ventriculography were sequentially conducted in 31 consecutive patients with angiographically proven coronary artery disease. The functional significance of various thallium redistribution patterns was assessed. The patients with an entirely complete (CR) or partial (PR) redistribution pattern had a higher global left ventricular ejection fraction than those with combined PR and no redistribution (NR), while patients with an entirely CR pattern did not have a statistically better ejection fraction than those with PR. Furthermore, myocardial segments with normal perfusion (N) and those with CR or PR had a higher regional ejection fraction than those with NR in the infero-apical area and the septal area. The regional ejection fraction was statistically higher in patients with CR than in those with PR in the septal area and higher, though not statistically significant, in the infero-apical area. The functional difference between groups with N and CR was not significant. Thus, we conclude that the redistribution patterns of dipyridamole thallium SPECT are closely correlated with systole function. Myocardium, in the presence of redistribution, will have a better functional performance in coronary artery disease.

The hospital records of 204 patients with acute myocardial infarction (AMI) admitted from August 1988 through July 1990 were reviewed. Of these, 138 patients who were admitted within 24 hours after onset of symptoms were enrolled in this retrospective study. In 138 patients (110 men, 28 women; aged 62.6 +/- 11.3 years), the mean prehospital time was 4.8 +/- 4.5 hours (median 3.0, range 0.5 to 24.0). Ninety-nine of these 138 patients were classified as an early presentation group (less than 6 hours); their mean prehospital time was 2.5 +/- 1.3 hours. Of these, 60 patients received thrombolytic therapy with intravenous streptokinase (SK), and their prehospital time was 2.3 +/- 1.2 hours, with mean time to SK therapy of 3.7 +/- 1.5 hours. The in-hospital mortality of these 60 patients was 16.7%. The remaining 39 patients, without SK therapy, had a higher in-hospital mortality (28.2%); their mean prehospital time was 2.7 +/- 1.3 hours. For the late presentation group (greater than or equal to 6 hours), the mean prehospital time was 10.6 +/- 4.3 hours and the in-hospital mortality was 7.7%. The frequency of severe congestive heart failure (Killip class III or IV) at admission was significantly higher in patients with early presentation, than with late presentation (30.7% vs 7.6%, p less than 0.05). The overall causes of death included congestive heart failure (79%), ventricular arrhythmia (8%) and underlying medical illness (13%). In conclusion, 43.4% of the AMI patients in this study received SK therapy, within a mean time of 3.7 +/- 1.5 hours after onset.(ABSTRACT TRUNCATED AT 250 WORDS)

Instances of left atrial (LA) thrombus and spontaneous echo contrast were evaluated by both transthoracic echocardiography (TTE) and subsequent transesophageal echocardiography (TEE) in 50 patients with rheumatic mitral stenosis (Group I) and 52 patients with non-rheumatic atrial fibrillation (Group II). Among these 102 patients, TEE detected LA thrombi in 16 patients (15.7%) and spontaneous echo contrast in 35 (34.3%). In contrast, TTE revealed LA thrombi in only 8 patients (7.8%) and spontaneous echo contrast in only 2 patients (2.0%). All of the LA thrombi and spontaneous echoes detected by TTE were also found by TEE. When TEE was applied, patients with spontaneous echo contrast had a significantly higher incidence of LA thrombus than did those without this echo (42.8% vs 1.5%, p less than 0.01). Spontaneous echo contrast was coexistent in all but one of the patients with LA thrombi (15 of 16, 93.7%). In Group I, the incidence of spontaneous echo contrast for patients with isolated or predominant mitral stenosis was high (68.3%) when TEE was applied, but this echo was not observed in any patient who had more than a moderate degree of mitral regurgitation. In Group II, 7 patients (13.5%) were also found to have spontaneous echo contrast, which could only be detected by TEE. Of these 7 patients, LA thrombus was noted in 4 by TEE, but only in 1 by TTE. Thus, it can be concluded that: (1) TEE is superior to TTE for detecting LA thrombus and spontaneous echo contrast; (2) spontaneous echo contrast in LA is not only frequently encountered in mitral stenosis without significant mitral regurgitation, but is also found in some patients with non-rheumatic atrial fibrillation; and (3) the presence of spontaneous echo contrast is associated with a higher incidence of LA thrombus and may be considered as a warning sign for further formation of LA thrombus.