The establishment of an endocarditis team(ET)[1] is a fundamental requirement for good practice, not only in the narrow context of reactive management of clinically overt infective endocarditis but also in the wider context of frontline mitigation of the risk of missed diagnosis of occult infective endocarditis(IE). It is in the latter context that point of care ultrasound(POCUS) might have a role beacuse of its wider availability and because it can be utilised as an extension of the physical examination to detect manifestations of IE such as splemonegaly and splenic infarction. .
The caveat is that, in the present state of technical expertise and equipment capability, the use of POCUS is associated with a trade-off between availability and diagnostic accuracy. Three cases exemplify this dilemma[2[,[3],[4].. None had cardiac murmurs, notwithstanding the fact that the presence of a murmur is the usual starting point for triggering the index of suspicion for IE. In each instance the use of POCUS appeared to be an extension of the clinical examination, aimed at exploring the differential diagnosis of the presenting clinical scenario.
The first patient, who had a history of intravenous drug use, presented with altered level of consciousness. Auscultation disclosed bilateral crackles but no murmurs. Electrocardiography showed right axis deviation and ST segment elevation in the inferolateral leads. POCUS disclosed the presence of a tricuspid valve vegetation. Formal transthoracic echocardiography(TTE), however, showed vegetations both on the tricuspid valve and on the mitral valve,. It was the latter which had given rise to coronary embolism and, hence, inferolateral ST segment elevation.. Computed tomography showed multiple areas of hyperdensity consistent with intracranial haemorrhage attributable to septic emboli[2].
The second patient presented with congestive heart failure but no murmurs. Although formal TTE was thought to be desirable it was not available on that day. In its place POCUS was implemented, and it showed mitral regurgitation as well as aortic regurgitation but vegetations were detected only on the mitral valve. On the strength of the POCUS findings the patient was transferred to a tertiary hospital where formal TTE showed vegetations on both the mitral valve and the aortic valves.[3[.
The third patient presented with fever. cough, and weight loss but no murmurs. POCUS showed a vegetation on the aortic valve and some irregularity on the mitral valve. Subsequent formal TTE showed vegetations on both the aortic and mitral valves[4].
Comment
These examples show POCUS to be a readily available frontline resource for initial work up of occult IE, albeit with the limitation of suboptimal diagnostic accuracy. To some extent, however, POCUS compensates for that deficiency, not only by being more readily available(thereby reinforcing the principle of "same day echocardiography", but also because POCUS has a multiorgan dimension whereby it can be utilised to detect extracardiac manifestations of IE such as splenomegaly, and embolic manifestations of IE such as splenic infarction and hepatic infarction[5]. In the latter study, where POCUS was utilised as an extension of the physical examination(to detect splenomegaly and hepatomegaly) in patients with bacteremia or candidemia, POCUS had a positive predictive value of 78% for detection of splenomegaly, positive predictive value of 100% for detection of splenic infarction, and a positive predictive value of 75% for detection of hepatic infarction[5]. POCUS (with back up from TTE) could also be utilised to screen for IE in prospective candidates for thrombolytic therapy of stroke so as to mitigate the risk of inappropriate thrombolysis attributable to missed diagnosis of IE as the underlying cause of stroke. The second case , where IE was the underlying cause of intracranial embolism[2],reinforces that principle.
I have no funding and no conflict of interest
References
[1]Sandoe JAT., Ahmed F., Arumugam P et al
Expert consensus recommendations for the use of provision of infective endocarditis services: updated guidance from the JJoint British Societies
Heart doi:10.1136/heartjnl-2022-321791
. [2] Cohen S., Ford L., Situ-LaCasse E., Tolby N
Infective endocarditis causing acute myocardial infarction
CUREUS 2020 DOI:10.7759/cureus.11245
[3] Kobenson L., Ma IWY., Olszynski P
A sinister point of care ultrasound(POCUS) finding in a patient with new heart failure
Canadian Journal of General Internal Medicine 2022;17:6-12
[4]Bugg CW., Berona K
Point-of -care ultrasound diagnosis of left-sided endocarditis
Western Journal of Emergency Medicine 2016;17:383--383
[5]Palmero SL., Zuniga MAL., Martinez VR et al
Point-of care ultrasound(POCUS) as an extension of the physical examination in patients with bacteremia or candidemia
Journal of Clinical; Medicine 2022;11:3636
DOI.org/10.3390/jcm 11133636

This study, in which subjects with systolic blood pressure(SBP) in the range 130 mm Hg-139 mm Hg were defined as being in the category of "high normal" blood pressure[1] is a reaffirmation of the dictum that "Essential hypertension can be defined as a rise in blood pressure....that increases risk of cerebral, cardiac, and renal events"[2]. According to that definition of hypertension subjects such as the ones shown to be at risk of a cardiac event such as atrial fibrillation(with its attendant risk of cerebral embolism) , as a consequence of a SBP of 130 mm Hg-139 mm Hg , should be allocated to the category of hypertension instead of being categorised as having "high normal" blood pressure. A similar categorisation should have been applied to otherwise healthy middle-aged men(mean aged 50) with SBP in the range 129 mm Hg-138 mm Hg who were shown to have a 1.5-fold increase in risk of atrial fibrillation(95% Confidence Interval 1.10 to 2.03) compared with middle aged men with SBP < 128 mm Hg[3].
Given the observation that "Throughout middle and old age, usual blood pressure is strongly and directly related to vascular(and overall) mortality , without any evidence of a threshold, down to at least 115/75 mm Hg"[4], the time might, perhaps, be overdue to invoke the concept proposed by Messerli et al that we should abandon the hypertension/normotension dichotomy and focus on global risk reduction, instead [2]. In that spirit of reduction of the risk of incident adverse cardiac events it has been shown that reduction of the risk of incident atrial fibrillation is achievable through intensive lowering of systolic blood pressure to a target level of <120 mm Hg[5]. Accordingly, the conversation that should take place between doctor and patient should be about goal blood pressure for mitigating the risk of complications such as incident atrial fibrillation, and atrial fibrillation-related stroke. That is the kind of dialogue that is most likely to generate compliance with medication and compliance with home blood pressure monitoring.
I have no conflict of interest.
References
[1]Kim J., Kim D., Jange E et al
Association of high normal blood pressure and impaired fasting glucose with atrial fibrillation
Heart doi.org/10.1136/heartjnl.2022-322094
[2] Messerli FH., Williams B., Eitz E
Essential hypertension
Lancet 2007;370:591-601
[3] Prospective Studies Collaboration
Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies
Lancet 2002;360:1903-1913
[4[ Grundvold I., Skretteberg PT., Liestol K et al
Upper normal blood pressures predict incident atrial fibrillation in healthy middle aged men
A 35 year follow up study
Hypertension 2012;59:198-204

[5]Soliman EZ., Rahman AKMF., Zhang Z-m et al
Effect of intensive blood pressure lowering on the risk of atrial fibrillation
Hypertension 2020;75:1491-1496

We read with great interest the editorial of Zhu et al (1). The authors have great theoretical knowledge and experience in the treatment of aortic valve regurgitation. We agree with their conclusion concerning personalised external aortic root support (PEARS) that “there are still many questions to be answered”. We would like to try to answer some of them.
Experience based on the first 100 operations in the Czech Republic (2) suggests that the indication for PEARS is limited to the patient with dilatation of the aortic root and/or ascending aorta and only trivial aortic regurgitation regardless of the origin of the disease. Implantation of PEARS should be considered as a preventive operation in group of patients that usually do not meet the criteria for valve sparing aortic valve replacement. In these patients the PEARS procedure can be performed as a measure to prevent further dilatation of the aorta and possible aortic dissection. The possibility of performing the operation without a cardiopulmonary bypass is certainly an advantage for the patient (2).
The authors worried about wall tension after implantation. It is generally known, that decrease of the diameter which is achieved by PEARS implantation, reduces wall tension according to the La Place law. This procedure in fact decreases wall tension and moreover the wall of the aorta is externally supported.
The fears about the viability of the aortic wall due to the continuous circumferential stress is not well-founded. The porous mesh does not affect the viability of the wall as we proved in our patient that had to be reoperated due to progression of aortic valve disease. The mesh was incorporated into the aortic wall without any signs of scar or necrosis. The same finding was by Pepper at al. (3).
It has been proved that after PEARS implantation there is no progression of aortic dilatation (4,5). This is also our experience with the first 100 patients in the Czech Republic. We found out that PEARS implantation prevented progression in dilatation of ascending aorta during follow-up of 18 months (1). As the longest surviving patient has PEARS implanted for more than 18 years without any progression of dilatation it can be postulated that the durability of this procedure would be excellent (6).
We are not sure if the authors understand well the surgical technique of implantation of the PEARS. The proper technique was published previously (7). In short, the mesh is sutured by several stitches to the aortic anulus that enables the fixation in a proper position. These stitches are not under any tension and therefore there is not any reason for pseudoaneurysm formation. The original seam of the mesh has to be sutured along the entire length by continuous suture
The same suture is performed from the main seam to both coronary ostia. In this way the entire aortic root and ascending aorta are wrapped with the mesh. There is no space between the edges of the seams and therefore no space for any dilatation or aneurysm formation.
We believe that PEARS implantation, if it is done with the proper technique and in a well indicated patient, is a very safe procedure with the potential for a stable long-term result.

 
Literature:
1. Zhu Y, Woo J. Has personalised surgery made another advancement in aortic root surgery? British Heart Journal. 2023.
2. Němec P, Pirk J, Skalský I, et al. Výsledky léčby externí podpory aortálního kořene a ascendentní aorty u prvních 100 pacientů v České republice. Cor Vasa 2022;64:579–583 https://e-coretvasa.cz/artkey/cor-202206-0002_outcomes-of-personalised-e...
3. Pepper J, Goddard M, Mohiaddin R, Treasure T. Histology of a Marfan aorta 4.5 years after personalized external aortic root support. Eur J Cardiothorac Surg 2015; 48:502–505
4. Van Hoof L, Rega F, Golesworthy T, et al. Treasure, Personalised external aortic root support for elective treatment of aortic root dilation in 200 patients, Heart 2021;107:1790–1795.
5. Izgi C, Newsome S, Alpendurada F, et al. External Aortic Root Support to Prevent Aortic Dilatation in Patients With Marfan Syndrome. J Am Coll Cardiol 2018;72:1095–1105
6. Treasure T, Austin C, Kenny LA, PepperJ. Personalized external aortic root support in aneurysm disease. Curr Opin Cardiol 2022:37(6):454-458
7. Nemec P, Kolarik M, Fila P. Personalized external aortic root support – how to implant it. Acta Chir Belg 2022;122:70–73

Liang et al. conducted a prospective study to predict major adverse cardiovascular events (MACE) in patients with hypertrophic cardiomyopathy (HCM) with special reference to molecular subtypes in HCM (1). Compared with the reference group with molecular subtype A, patients in molecular subtype D presented an increased risk of developing MACE, with the adjusted hazard ratio (HR) (95% CI) of 2.78 (1.18 to 6.55). I have comments about the study.

The authors understand the unstable estimation by multivariate analysis, which would be partly caused by the limited number of events. When conducting Cox regression analysis, they used sex, age, and two conventional cardiac biomarkers. As they classified molecular subtypes into four groups, a total of 7 independent variables were used for the analysis. There is a recommendation that the number of events per independent variable in Cox regression analysis are required ≥10 for prediction model (2,3). If the authors have concerned about the association between molecular subtypes in HCM and MACE events, strict criteria for the number of events can be relaxed (4). Although there is a description that the total number of events was 78 in Table 2, the number of patients with event was 66 in Table 3. I suppose that some patients had more than single event. I recommended to add MACE events by continuing follow-up to fulfill the statistical requirement.

When we see survival curve in Figure 2, remarkable difference in the risk of MACE event among subtypes was observed after 2 years. Are there any biological explanations for the accelerated risk of MACE events in molecular subtype D ? Anyway, results of genetic testing cannot explain the increased risk of MACE events in molecular subtype D.

Reference
1. Liang LW, Raita Y, Hasegawa K, et al. Proteomics profiling reveals a distinct high-risk molecular subtype of hypertrophic cardiomyopathy. Heart 2022;108(22):1807-14.
2. Concato J, Peduzzi P, Holford TR, et al. Importance of events per independent variable in proportional hazards analysis. I. Background, goals, and general strategy. J Clin Epidemiol 1995;48(12):1495-501.
3. Peduzzi P, Concato J, Feinstein AR et al. Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates. J Clin Epidemiol 1995;48(12):1503-10.
4. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 2007;165(6):710-8.