Sir, Having been involved in trying to arrange a widely, even internationally, afreed schedule of prophylaxis, we read your Editorial and the abstract ofDr Oakley and others2 with considerable interest. We3 have already agreed that amoxycillin may be a good answer to the dental problem but we feel it is still premature to give it unqualified approval as the definitive prophylaxis when given in a single dose before the following points have been elucidated:(1) In the study by Oakley et al., amoxycillin was by no means 100% effective. (2) L forms or persisters were not looked for in blood and have not yet to our knowledge been studied in the laboratory. All penicillins take at least three days to "sterilise" a culture of sensitive bacteria. (3) The rabbit experimental model has not been used to test this regimen. All other regimens have been assessed by this valuable method and incidentally a single dose of benzylpenicillin failed to work in this test.4 McGowan of Glasgow and others are at present setting up a study of amoxycillin and the results are awaited with interest. The suggestion that amoxycillin should be given to all people undergoing dental extraction presents a new departure in medicine. Never before, to our knowledge, has a drug been advised to cover a very common procedure which is predominately carried out in normal people and whose use would be of possible benefit to a tiny minority. Figures for the dangers, the shortfalls, and the cost of this should be available before any general recommendations are made. While some hopeful data exist for amoxycillin, the evidence for a single dose of erythromycin as an alternative appears to have no supporting evidence. If this drug is used, surely it must be given for two to three days. Finally, we know from our own experience that much prejudice and entrenched medical opinion already exist in this difficult field. Any premature new recommendations could lead to the compounding of this situation rather than its improvement. We therefore recommend a pause while the above matters are sorted out, before the suggested changes are generally accepted. We have reviewed the wider problems of prophylaxis elsewhere.3

Prevention of infective endocarditis

Heart Disease A Textbook of Cardiovascular Medicine

This unique text covers all aspects of valvular heart disease, including normal valve anatomy and physiology, pathophysiology, modes of investigation, assessment and treatment of specific valve lesions, valve surgery (both medical and surgical aspects), treatment in pregnancy or during non-cardiac surgery, and the devastating complication of infective endocarditis, in an easy-to-read, accessible format.

Valvular heart disease

Objective:To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.Methods:Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the “levels” of quality of evidence into high (A), mod

Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients—part Ii: Cardiac Ultrasonography

Pulmonary hypertension is defined as a mean arterial pressure of ≥25 mmHg as confirmed on right heart catheterisation. Traditionally, the pulmonary arterial systolic pressure has been estimated on echo by utilising the simplified Bernoulli equation from the peak tricuspid regurgitant velocity and adding this to an estimate of right atrial pressure. Previous studies have demonstrated a correlation between this estimate of pulmonary arterial systolic pressure and that obtained from invasive measurement across a cohort of patients. However, for an individual patient significant overestimation and underestimation can occur and the levels of agreement between the two is poor. Recent guidance has suggested that echocardiographic assessment of pulmonary hypertension should be limited to determining the probability of pulmonary hypertension being present rather than estimating the pulmonary artery pressure. In those patients in whom the presence of pulmonary hypertension requires confirmation, this should be done with right heart catheterisation when indicated. This guideline protocol from the British Society of Echocardiography aims to outline a practical approach to assessing the probability of pulmonary hypertension using echocardiography and should be used in conjunction with the previously published minimum dataset for a standard transthoracic echocardiogram.

https://erp.bioscientifica.com/downloadpdf/journals/echo/5/3/ERP-17-0071.pdf

Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography.

Extracorporeal life support can be viewed as a spectrum of modalities based on modifications of a cardiopulmonary bypass circuit to provide cardiac and respiratory support, which can be used for extended periods, from hours to several weeks. Extracorporeal membrane oxygenation (ECMO) is among the most frequently used forms of extracorporeal life support. It can be configured for venovenous blood flow, to provide adequate oxygenation and carbon dioxide removal in isolated refractory respiratory failure, or in a venoarterial configuration, when support is required for cardiac and/or respiratory failure. Echocardiography plays a fundamental role throughout the entire journey of a patient supported on ECMO. It provides information that assists in patient selection, guides the insertion and placement of cannulas, monitors progress, detects complications, and helps in determining cardiac recovery and the weaning of ECMO support. Although there are extensive published data regarding ECMO, particularly in the pediatric population, there is a paucity of data outlining the role of echocardiography in guiding the management of adult patients supported by ECMO. ECMO is likely to become an increasingly used form of cardiorespiratory support within the critical care setting. Hence, clinicians and sonographers who work within echocardiography departments at institutions with ECMO programs require specific skills to image these patients.

The role of echocardiography in the management of patients supported by extracorporeal membrane oxygenation.

Echocardiography is the major imaging modality used for the diagnosis of infective endocarditis (IE). It is also useful in detecting the complications of IE which often necessitate surgical intervention and strongly influence patient outcomes. Transesophageal echocardiography (TEE), with proven superiority over transthoracic echocardiography (TTE) for the detection of vegetations and complications such as abscess, should be performed in the vast majority of cases especially when TTE image quality is poor or implanted devices are present. Three-dimensional (3D) TEE provides enhanced display of anatomic-spatial relationships allowing more precise delineation of complex pathology, particularly of the mitral valve and annulus. Importantly, echocardiographic findings can be non-specific and should always be interpreted in the context of the pre-test probability of IE based on careful clinical assessment. IE remains a challenging disease associated with variable clinical presentations, and high mortality. Whenever IE is suspected, echocardiography should be utilized early for both diagnosis and detection of complications.

Update on echocardiography in the management of infective endocarditis.

Contrast microsphere enhancement of the tricuspid regurgitant spectral Doppler signal - Is it still necessary with contemporary scanners?

https://espace.library.uq.edu.au/view/UQ:376725/UQ376725_OA.pdf

Comparison of surgical repair and percutaneous stent implantation for native coarctation of the aorta in patients ≥ 15 years of age.

Echocardiography is fundamental for the management of infective endocarditis (IE) across all stages of the illness including diagnosis, surveillance during medical therapy, identification of prognostic markers, planning perioperative intervention, postoperative assessment, and follow-up after completion of definitive therapy. Modern era echocardiography (echo) offers outstanding temporal and spatial image resolution, providing the opportunity for early diagnosis of this life-threatening infection. Emerging imaging modalities, such as real-time three-dimensional (3D) echocardiography, offer a novel way of readily visualizing the extent of intracardiac infection and the relationship of pathology to adjacent cardiac structures, well before surgical intervention, without radiation exposure or significant risk to the patient. Echocardiography can have a positive impact on the management of every stage of this disease, with the opportunity to improve outcomes.

/pdf/advanced-echocardiography-for-the-diagnosis-and-management-hxprznsenu.pdf

Advanced Echocardiography for the Diagnosis and Management of Infective Endocarditis

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