READERS’ COMMENTS
Role of Heart Failure and
Infectious Etiology in
Infective Endocarditis With
New-Onset Atrial Fibrillation
We read the recent study by Ferrera
et al1 highlighting the role of atrial
fibrillation (AF) in patients with infec-
tive endocarditis. We would like to offer
our thoughts on the correlation of heart
failure (HF) with AF and the microbi-
ology in these patients. As correctly
pointed out by the investigators it is
indeed difficult to establish a temporal
relation between HF and AF in these
patients. However, on closer evaluation
of their cohort, we note the following
points: (1) in patients with new-onset
AF, the left atrial (LA) diameter was
significantly larger than in patients
maintaining sinus rhythm and (2) 53%
of their patients presented with “heart
failure” per the investigators, which as
we understand, is an episode of acute
decompensation. LA dimension
(defined by LA volume index) in pa-
tients with normal filling pressures and
normal left ventricular (LV) ejection
fraction (EF) is an independent mortal-
ity predictor.2 LAVI has been noted to
be an accurate marker of chronic HF
with preserved EF and along with filling
pressures and tissue Doppler imaging, a
marker of acute HF.3 Taken in combi-
nation, it may be speculated that these
patients had chronic HF with acute
decompensation during their index
admission. Furthermore, the distinction
between HF with reduced or preserved
EF in this cohort is crucial because the
consequences of AF would be more
pronounced in the HF with preserved
EF cohort because of loss of late dia-
stolic filling.4
Although the investigators have used
radiographic criteria for diagnosis of
HF, a meta-analysis demonstrated chest
radiography to be only 76% specific and
67% sensitive in contrast to more robust
diagnostic techniques.5 In addition, the
present study does not elaborate on
New York Heart Association classes,
cardiac biomarker levels, LV function,
including LVEF, filling pressures, and
tissue Doppler imaging velocities. This
lack of distinction between acute versus
chronic and compensated versus
decompensated HF could have altered
Am J Cardiol 2016;117:1028e1030
0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved.
the assessment of HF during multivar-
iate analysis because of inappropriate
risk stratification. Furthermore, in their
multivariate analysis, the investigators
highlighted HF as an independent pre-
dictor of mortality and that has been
shown to be true across multiple studies
in patients with infective endocarditis
resulting in a class IB indication for
surgery.6 However, their conclusion (as
highlighted in the discussion and
Figure 1) that AF leads to HF in a
unidirectional fashion, and not using a
bidirectional relation, is not robustly
supported by their data because of the
reasons mentioned previously.
The previously mentioned observa-
tions lead us to speculate that HF may
have been underdiagnosed in their
cohort and could have been a driver for
AF in addition to the opposite relation.
As such, Ferrera et al’s hypothesis of
AF being a marker rather than a medi-
ator for mortality might be extendable
to HF too and merits further investiga-
tion evaluating causation rather than
association.
From a microbiological standpoint,
we note that nonecommunity-acquired
(i.e., health careeacquired) infective
endocarditis was higher in the new-
onset AF cohort, which is an indepen-
dent marker of worse prognosis.7 This
information, in combination with the
lack of data on how many eligible pa-
tients did not receive cardiac surgery
due to increased risk of surgery, severity
of illness, or patient/provider prefer-
ence, can potentially confound the
assessment of mortality in this cohort
and need further elaborating before
attributing these differences to AF.
Saraschandra Vallabhajosyula, MBBS
Daniel C. DeSimone, MD
Nandan S. Anavekar, MBBCh
Rochester, Minnesota
10 December 2015
1. Ferrera C, Vilacosta I, Fernandez C, Lopez J,
Sarria C, Olmos C, Vivas D, Saez C, Sanches-
Enrique C, Ortiz-Bautista C, San Roman JA.
Usefulness of new-onset atrial fibrillation, as a
strong predictor of heart failure and death in
patients with native left-sided infective endo-
carditis. Am J Cardiol 2016;117:427e433.
2. Patel DA, Lavie CJ, Gilliland YE, Shaw SB,
Dinshaw HK, Milani RV. Prediction of all-
cause mortality by the left atrial volume index
in patients with normal left ventricular filling
pressure and preserved ejection fraction. Mayo
Clin Proc 2015;90:1499e1505.
3. Shuai XX, Chen YY, Lu YX, Su GH, Wang
YH, Zhao HL, Han J. Diagnosis of heart failure
with preserved ejection fraction: which pa-
rameters and diagnostic strategies are more
valuable? Eur J Heart Fail 2011;13:737e745.
4. Zakeri R, Chamberlain AM, Roger VL, Red-
field MM. Temporal relationship and prog-
nostic significance of atrial fibrillation in heart
failure patients with preserved ejection frac-
tion: a community-based study. Circulation
2013;128:1085e1093.
5. Mant J, Doust J, Roalfe A, Barton P, Cowie
MR, Glasziou P, Mant D, McManus RJ,
Holder R, Deeks J, Fletcher K, Qume M,
Sohanpal S, Sanders S, Hobbs FD. Systematic
review and individual patient data meta-
analysis of diagnosis of heart failure, with
modelling of implications of different diag-
nostic strategies in primary care. Health Tech-
nol Assess 2009;13:1e207.
6. Baddour LM, Wilson WR, Bayer AS,
Fowler VG Jr, Tleyjeh IM, Rybak MJ,
Barsic B, Lockhart PB, Gewitz MH,
Levison ME, Bolger AF, Steckelberg JM,
Baltimore RS, Fink AM, O’Gara P, Taubert
KA; American Heart Association Committee
on Rheumatic Fever, Endocarditis, and
Kawasaki Disease of the Council on Car-
diovascular Disease in the Young, Council
on Clinical Cardiology, Council on Cardio-
vascular Surgery and Anesthesia, and
Stroke Council. Infective endocarditis in
adults: diagnosis, antimicrobial therapy, and
management of complications: a scientific
statement for healthcare professionals from
the American Heart Association. Circulation
2015;132:1435e1486.
7. Lomas JM, Martínez-Marcos FJ, Plata A, Iva-
nova R, Gálvez J, Ruiz J, Reguera JM, Nour-
eddine M, de la Torre J, de Alarcón A; Grupo
Andaluz para el Estudio de las Infecciones
Cardiovasculares (Andalusian Group for the
Study of Cardiovascular Infections) at the
Sociedad Andaluza de Enfermedades Infec-
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http://dx.doi.org/10.1016/j.amjcard.2015.12.019
Hospital Volume and
In-Hospital Outcomes After
Transcatheter Aortic Valve
Implantation
We read with great interest, Kim
et al’s1 study regarding the association
of hospital volume with in-hospital
outcomes after transcatheter aortic
valve implantation (TAVI) in the
United States. We would like to bring to
the investigators’ attention the results
from our study using the Nationwide
Inpatient Sample from 2012 published
www.ajconline.org