Transesophageal Echocardiography in Identifying Fungal Vegetations in the Right Cardiac Chambers in an Intensive Care Unit Patient

LETTERS TO THE EDITOR

Transesophageal Echocardiography in Identifying Fungal Vegetations in the Right Cardiac Chambers in an Intensive Care Unit Patient To the Editor: Echocardiography is currently considered one of the main tools in the diagnosis and treatment of infective endocarditis.1,2 By

Fig 1. (A and B) A transgastric view of the tricuspid valve and right cardiac chambers depicting multiple fungal vegetations (arrows). PA, pulmonary artery; A, aorta. (Color version of figure is available online.)

535

using echocardiography, it is possible to localize the site of vegetations exactly and also to estimate their extent in the cardiac chambers. We present a very rare case of fungal endocarditis involving the right ventricle. This case is noteworthy for the unusual and impressive echocardiographic appearance of the fungal vegetations. A 70-year-old man with a 2-year history of myelodysplastic syndrome was admitted to the intensive care unit after neurosurgery for a subdural hematoma. After 1 day in the intensive

536

LETTERS TO THE EDITOR

care unit, the patient developed multiple organ failure and finally a cardiorespiratory arrest. Resuscitation attempts were successful, and transesophageal echocardiographic (TEE) examination was chosen for evaluation of cardiac function. Surprisingly, TEE revealed multiple vegetative materials located on the right cardiac walls protruding into the right ventricle and also affecting the tricuspid valve (Fig 1). The masses were mobile and round to oval-shaped with a rough surface. Afterwards, laboratory results disclosed anemia, thrombocytopenia, and leukopenia. In addition, a head computed tomography scan revealed multiple embolic lesions. Blood and bronchial secretion cultures grew Mucor spp and confirmed the fungal infection. Despite aggressive antifungal therapy, the patient died 48 hours later. In conclusion, TEE contributed to the diagnosis of a very rare case of fungal infection affecting the tricuspid valve and the right cardiac chambers. Christina Mandila, MD George Koukoulitsios, MD Vasilios Panagoulias, MD Theodosios Saranteas, MD Andreas Karabinis, MD Department of Intensive Care Unit General State Hospital of Athens Athens, Greece REFERENCES 1. Feuchtner GM, Stolzmann P, Dichtl W, et al: Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings. J Am Coll Cardiol 53:436-444, 2009 2. Aggarwal N, Pannu HS, Verma P, et al: Native aortic valve endocarditis caused by Candida sake. J Heart Valve Dis 17:194-196, 2008 doi:10.1053/j.jvca.2009.05.019

Assessment of Neurocognitive Function and Neuroprotective Strategies in Cardiac Surgery To the Editor: We read with interest the article published by Sahu et al1 in which the authors report the findings of 2 different rewarming strategies in patients undergoing coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). The authors conclude that weaning from CPB at a nasopharyngeal temperature of 33°C (v 37°C) followed by passive rewarming in the intensive care unit (ICU) may be a useful strategy to lower postoperative neurocognitive dysfunction and to decrease morbidity. We agree with the authors that the reduction of neurocognitive impairment can be achieved by the avoidance of brain hyperthermia in the bypass and postbypass period and by the usage of a slow rewarming rate with decreased peak temperature differences. Although these findings have been already noted by several investigators, we believe that the presented

study has methodologic limitations as indicated by the authors. Likewise, the interpretation of results and conclusions requires a critical discussion. A limitation caused by the applied neurocognitive test and its utilization in the selected population remains completely unmentioned by the authors. However, particulary in cardiac surgery, there are several factors concerning the design of studies in the field of perioperative neurocognitive deficit that should remind us to avoid systemic bias and misunderstandig results. First, a neuropsychologic test used must be validated and comparable with other, previously used tests reported in the literature. The last consensus conference in this field recommended a list of neuropsychologic tests that were considered to represent necessary components of any battery of tests for the neuropsychologic assessment of cognitive impairment in cardiac surgical patients.2 Unfortunately, the Indian adaptation of the Wechsler Adult Intelligence Scale used by Sahu et al was not identified by this multidisciplinary group. The WAIS-R was suggested as a neurocognitive test covering higher cortical and language function, but it was not recommended for the measurement of memory function or the testing of attention, concentration, and psychomotor performance in cardiac surgery. The lack of comparable studies with the neuropsychologic examination method and its limited information concerning sensitivity, specificity, and predictive value makes a comparison of collected data with the international literature difficult. Second, the article contains no information about details of surgical technique (eg, ascending aorta side-clamping and venting) and about the patient’s possible respiratory complications in the ICU. Similary, a preoperative echocardiographic assessment of the ascending aorta for the purpose of detecting aortic atheroma was either not carried out or not reported. Intergroup differences in these factors may have been present and along with the increased time on CPB in the rewarming group, might have been led, even without the negative effects of hyperthermia, to a higher degree of neurocognitive dysfunction in the warmer subgroup. Third, conflicting studies exist on pharmacokinetics and the possible extracranial origin of the S100␤ protein. Some investigators believe that the concentration of S100␤ remains high in 13% of patients after 24 hours postoperatively, even without cerebral impairment.3 In addition, a delayed or late (15-48 hours) S100␤ release can occur as the result of traumatized fat, muscle, bone marrow, or respectively as a consequence of embolism from ascending aortic plaques or retransfusion of salvaged warm blood from CPB in the ICU.4,5 Thus, at the present time, the literature does not support drawing inferences on central nervous system on the basis of measurements of S100␤ levels. In the setting of CPB, a sustained elevation of S100␤ with a simultaneous increase of other cerebral biomarkers (GFAP and NSE) might have been more sensitive of cerebral injury or neuropsychologic deficit. Fourth, we hypothesize that the time of the assessment of neurocognitive function on the 5th day after surgery and the absence of a follow-up may also affect the study results and its reproductibility. Increased familiarity with the test, depression, fatigue, mood state, anxiety, sleep deprivation, and the usage of different postoperative medications (analgetics, antidepres-