Infective endocarditis (IE) continues to have high rates of adverse outcomes, despite recent advances in diagnosis and management. Although the use of computer tomography and nuclear imaging appears to be increasing, echocardiography, widely available in most centers, is the recommended initial modality of choice to diagnose and consequently guide the management of IE in a timely-dependent fashion. Echocardiographic imaging should be performed as soon as the IE diagnosis is suspected. Several factors may delay diagnosis, for example echocardiography findings may be negative early in the disease course. Thus, repeated echocardiography is recommended in patients with negative initial echocardiography if high suspicion for IE persists, in patients at high risk. However systematic echocardiographic screening should not be utilized as a common tool for fever, but only in the presence of a reasonable clinical suspicion of IE. It may increase the risk of false positive rates of patients requiring IE therapy or may exacerbate diagnostic uncertainty about subtle findings. Considering the complexity of the disease, the echocardiographic proper use should be increasingly time-efficient and focused on the correct identification of IE lesions and associated complications. The path to identify patients who need surgery passes through an echocardiographic skill ensuring the identification of the cardiac anatomical structures and their involvement on the destructive infective extension. We pointed out the role of echocardiography focused on the correct identification of IE distinctive lesions and the associated complications, as part of a diagnostic strategy, within an integrated multimodality imaging, managed by an “endocarditis team”.

Background. Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (ACP) or retrograde. In recent years nadir temperature progressively increased to 26-28 °C (moderately hypothermic circulatory arrest, MHCA), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10-minute of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming, DR) can provide a neuroprotection and a lower body protection similar to that provided by MHCA+ACP. Methods. Two-hundred-ten patients were included in the study. DHCA+DR was used in 59 patients and MHCA+ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE) or permanent (permanent neurologic deficit, PND), and need of renal replacement therapy (RRT). Results. Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%) and PNDs in 10 (4.8%). Twenty-three patients (10.9%) needed RRT. Death+PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs and death+PND, but need of RRT (OR 7.39, CI 1.37-79.1) and composite endpoint (OR 8.97, CI 1.95-35.3) were significantly lower in DHCA+DR group compared with MHCA+ACP group. Conclusions. The results of our study demonstrate that DHCA+DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA+ACP. However, the data suggests that DHCA+DR when compared with MHCA+ACP provides better renal protection and reduced prevalence of composite endpoint.

Left atrial intramural hematoma (LAIH) is an uncommon entity for which a timely diagnosis is critical for decision making. Cardiac surgical or catheter-based procedures are potential causing factors. Though cardiac computerized tomography and magnetic resonance are highly accurate diagnostic modalities, their role is limited by the lack of widespread availability. The present clinical case illustrates the diagnostic features of LAIH that can be obtained using echocardiography at the bedside in critically ill patients. We report a case of LAIH, that followed a catheter ablation procedure and was complicated by cardiac and cerebral ischemia. Cardiac surgical management was required.