Accuracy of 18F-FDG PET/CT in patients with the suspicion of cardiac implantable electronic device infections: good for pocket, not so good for endocarditis

Introduction

The usefulness of 18F-FDG PET/CT in the diagnosis of infective endocarditis (IE) associated with cardiac implantable electronic devices (CIED) is not well established.

Purpose

To assess the diagnostic yield of 18F-FDG PET/CT in patients with suspected CIED infections, placing special emphasis on differentiating between pocket infection (PI) and CIED-IE.

Methods

From 2013 to 2018, all patients (n=63) admitted to a tertiary care hospital with suspected CIED infection were prospectively recruited, undergoing a thorough diagnostic work-up that included blood cultures extraction, transthoracic (TTE) and transoesophageal echocardiography (TEE) and a PET/CT. When device explantation was required, material from the pocket, generator and leads were also cultured. The gold standard for the diagnosis of CIED-IE was a positive lead culture in the absence of PI when percutaneous extraction was performed or a positive culture from a surgically removed lead. In spite of negative lead cultures, the presence of typical TEE images of vegetations in a clinical context of positive blood cultures was also considered as CIED-IE.

Results

After the whole diagnostic process, 14 (22.2%) cases corresponded to isolated PI and 13 (20.6%) were categorized as CIED-IE. Considering radionuclide uptake in the intracardiac portion of the lead, values of sensitivity, specificity and global diagnostic accuracy of PET/CT for CIED-IE were 38.5%, 98.0% and 85.7%, respectively. Positive and negative likelihood ratio values, 19.2 and 0.6 respectively, suggest that a positive PET/CT is much more probable to correspond to a patient with CIED-IE, whereas it is not possible to exclude this diagnosis in case of a negative result. In the case of PI, fair sensitivity (72.2%) and good specificity values (95.6%) were obtained. Extracardiac lead SUVmax and SUVratio in PI were good, with an area under the ROC curve (AUC) of 0.870 and 0.879, respectively. However, semiquantitative analysis was not useful for the diagnosis of CIED-IE.

Conclusions

In patients with suspected CIED infection, the yield of 18F-FDG PET/CT differs depending on the site of infection, showing a very high specificity but poor sensitivity in CIED-IE; so negative studies must be interpreted with caution if the suspicion of CIED-IE is high.

ROC curves SUVmax and SUV ratio for PI

Funding Acknowledgement

Type of funding source: None

Inter and intraobserver variability in the echocardiographic measurement of vegetations in infective endocarditis

Introduction and objectives

The indication for surgery to prevent embolism in infective endocarditis includes four clinical scenarios and three different echocardiographic measurements of the maximal vegetation diameter. These cut-off points are completely arbitrary and not evidence-based. Our hypothesis is that the vegetation diameter is not an appropriate surgical criterium. The goal of the study is to analyze the inter and intra-observer variability in this measurement and to compare the surgical indications agreement based on these parameters.

Methods

Two trained echocardiographers have measured the maximal vegetation diameter by transesophageal echocardiogram in 67 consecutive patients with definite infective endocarditis in an off-line workstation. The inter- and intra-observer variability was calculated by the interclass correlation coefficient and with the Bland-Altman analysis. The relationship between the strength of agreement for the cut-off points of 10 and 15 mm was also calculated.

Results

Intra and inter-observer interclass correlation coefficient in the measurement of the maximal longitudinal diameter of the vegetations were 0.872 (0.805–0.917) and 0.757 (0.642–0.839) respectively. The strength of agreement of the intra and inter-observer analysis for the cut-off point of 10 mm were 0.674 (0.485–0.862) and 0.533 (0.327–0.759). For the cut-off point of 15 mm they were 0.696 (0.530–0.862) and 0.475 (0.270–0.679).

Conclusions

The variability in the measurements of the maximal longitudinal diameter by transesophageal echocardiogram between two experimented echocardiographers is good. Nonetheless, surgical indications based on the cut-off points recommended in the European guidelines would have changed in an unacceptable high proportion of patients. Therefore, we suggest that these indications should be revised in the light of our results.

Funding Acknowledgement

Type of funding source: None

Predictive model of in-hospital mortality in left-sided infective endocarditis

INTRODUCTION AND OBJECTIVES

Infective endocarditis (IE) is a complex disease with high in-hospital mortality. Prognostic assessment is essential to select the most appropriate therapeutic approach; however, international IE guidelines do not provide objective assessment of the individual risk in each patient. We aimed to design a predictive model of in-hospital mortality in left-sided IE combining the prognostic variables proposed by the European guidelines.

METHODS

Two prospective cohorts of consecutive patients with left-sided IE were used. Cohort 1 (n=1002) was randomized in a 2:1 ratio to obtain 2 samples: an adjustment sample to derive the model (n=688), and a validation sample for internal validation (n=314). Cohort 2 (n=133) was used for external validation.

RESULTS

The model included age, prosthetic valve IE, comorbidities, heart failure, renal failure, septic shock, Staphylococcus aureus, fungi, periannular complications, ventricular dysfunction, and vegetations as independent predictors of in-hospital mortality. The model showed good discrimination (area under the ROC curve=0.855; 95%CI, 0.825-0.885) and calibration (P value in Hosmer-Lemeshow test=0.409), which were ratified in the internal (area under the ROC curve=0.823; 95%CI, 0.774-0.873) and external validations (area under the ROC curve=0.753; 95%CI, 0.659-0.847). For the internal validation sample (observed mortality: 29.9%) the model predicted an in-hospital mortality of 30.7% (95%CI, 27.7-33.7), and for the external validation cohort (observed mortality: 27.1%) the value was 26.4% (95%CI, 22.2-30.5).

CONCLUSIONS

A predictive model of in-hospital mortality in left-sided IE based on the prognostic variables proposed by the European Society of Cardiology IE guidelines has high discriminatory ability.

Electromechanical decoupling with multisite onset of mechanical contraction in patients with different underlying heart diseases derived to gated-SPECT

Backgroud/Introduction

Varying degrees of left ventricle (LV) mechanical dyssynchrony have been detected in some patients without electrical dyssynchrony. However, the site of onset of ventricular mechanical contraction as part of the electromechanical coupling process has not been fully described.

Purpose

To characterize LV contractile dynamics associated with multisite onset of mechanical contraction (OMC).

Methods

Phase histograms at rest were obtained in a sample of consecutive patients referred to 99mTc-MIBI gated-SPECT (radiotracer dose at rest: 925 MBq). Visual interpretation was performed through a semi-quantitative perfusion scale from 0 to 4 in a 17-segment model. Automated analysis included segmental summed rest, stress and difference scores (SRS, SSS and SDS), and also rest and post-stress functional parameters. Applying SyncTool from Emory Cardiac Toolbox® we obtained peak amplitude (PA), standard deviation (PSD) and phase bandwidth (PBW) indexes from resting phase histogram, detecting the site of OMC in LV. Then, we detected the patients with multisite (“multipoint”) OMC, defined as the onset in at least 3 of 17 segments. Latest site of mechanical contraction was recorded in last 10–30 degrees of phase. Histogram indexes were compared with a control group from our sample (n=24) and with controls reported by Chen J (n=90) by paired t test (p=0.05, two tailed).

Results

Multisite OMC was found in 19/137 patients (14%); affected from chronic coronary artery disease (n=13), hypertensive heart disease (n=2), inflammatory cardiomyopathy (n=1), hypertrophic cardiomyopathy (n=1) and nonischemic dilated cardiomyopathy (n=2). ECG showed left bundle branch block in one case and biventricular pacing in another. Multisite OMC was associated with diabetes (47.3%), lower LVEF (44.2±15.3%) and higher cavitary volumes (104.5±61.4 ml), SRS (17.0±10.7%) and incidence of fixed defects attributed to old infarct (77.8%); p<0.05 for all comparisons. Subjects with multisite OMC and chronic coronary disease (n=13) were 63±13 years old, 54% diabetic, LVEF=39.9±13.6%, telesystolic LV volume=112.4±64.9 ml, SRS=12.5% and SDS=4.2%. All patients with multisite OMC exhibited marked mechanical dyssynchrony at rest (PA=121.7±16.3, PSD=47.6±19.8, PBW=148.3±64.2 degrees (p<0.05 for the comparisons of PSD and PBW with sample controls and for the comparisons of all indexes with reported controls). In 4 of them (21%) a multisite late mechanical contraction was also detected.

Conclusions

Electromechanical decoupling with “multipoint” OMC is not infrequently found in patients referred to gated-SPECT, even in the absence of wide QRS complex. This subpopulation of patients is characterized by several functional high risk markers. Additional prognostic implications of this mechanical substrate, that seems to be common to several heart diseases, deserves further evaluation in large series subjected to prolonged clinical and physiological follow-up.

Funding Acknowledgement

Type of funding source: None

'Aorta code' implementation and preliminary results of a multidisciplinary protocol for patients with acute aortic syndrome

Background

Expediting life-saving care for patients with acute aortic syndrome (AAS) through multi-disciplinary code protocols is a potential method to improve outcomes. Other code protocols for cardiovascular emergencies, such as ST-elevation myocardial infarction and stroke have shown excellent results.

Aim

To examine the implementation and preliminary results of a code protocol “Aorta Code” for patients with AAS in a healthcare framework of a 4-hospital network in our city by reviewing the number of patients detected, patient's transference time, aortic surgery and patient's outcome during a trial period of 10 months (April 2019-January 2020). A comparison with a previous 2-year period with standard of care management of AAS was performed.

Methods

“Aorta Code” uses a specific diagnostic algorithm to improve detection of patients with AAS at the emergency room, facilitates their quick transfer to the referral hospital by activating a paging system, and places acute cardiovascular care unit, operating room and surgeons specialized in aortic pathology on standby.

Results

Compared to a previous 2-year period (2017–2018) (group I), the current implementation of “Aorta Code” in a period of 10 months (group II) in our 4-hospital network involving the healthcare of 1.100000 inhabitants resulted in the detection of more patients with AAS (group-I: n=18 patients (0.8 patients/month), group-II: n=19 patients (1.9 patients/month); p=0.013). AAS detection in secondary hospitals importantly increased (33.3% vs 63.8%, p=0.07). The “Aorta Code” achieved a significant decrease in patient's transference time to referral hospital (group-I: median 259 min (IQR 150–1911), group-II: median 129 min (IQR 95.5–167.25); p=0.035). There was a marked reduction in the number of surgeons involved in the “Aorta Code” (group-I= 7 cardiac, 6 vascular, group-II= 2 cardiac, 2 vascular). Thirty-day mortality was lower in group-II in the whole AAS cohort (group-I= 22.2%, group-II= 12.5%; p=0.660) and in type A AAS (28.6% vs 18.2%, p=0.661). Misdiagnosis rate (false-calls): 11 patients (7 of them with non-acute aortic disease).

Conclusion

“Aorta Code” facilitates detecting patients with AAS at the emergency room, speeds them to the referral hospital center, allows patients to be treated by surgeons specialized in aortic surgery and improves patient's outcome. Further prospective studies examining the utility of “Aorta Code” are warranted.

Funding Acknowledgement

Type of funding source: None

Prognostic benefit of urgent cardiac surgery in left-sided infective endocarditis

Background

Cardiac surgery is required in approximately 50% of patients with left-sided infective endocarditis (IE) being a high-risk procedure specially during active phase of the disease.

Purpose

To evaluate the impact of cardiac surgery in the in-hospital mortality of left-sided IE.

Methods

We used a prospective cohort of consecutive patients with definite left-sided IE between 2000 and 2017 (n=1002). A predictive model of in-hospital mortality was derived by adding the variable cardiac surgery to the already published ENDOVAL score. The benefit of cardiac surgery was calculated with the mean difference between the risk of in-hospital mortality considering urgent surgery and considering no surgery for each patient.

Results

The predictive model showed good discriminative capacity with an area under the ROC curve of 0.861 (95% CI: 0.830 - 0.891) and a good calibration (p-value in the Hosmer-Lemeshow test of 0.353). Figure shows the in-hospital mortality prediction of each patient in case of no-surgery (orange), urgent surgery (yellow) or real decision (blue). Mean reduction of in-hospital mortality risk in case of surgery for patients with a theoretical risk of in-hospital mortality between 0–20% in absence of surgery was 3.2±1.6%. For patients with a theoretical risk between 20–40% in absence of surgery the mean reduction was 8.1±1.1%. For patients with a theoretical risk between 40–60% in absence of surgery the mean reduction was 10.7±0.3%. For patients with a theoretical risk between 60–80% in absence of surgery the mean reduction was 9.7±0.9%. For patients with a theoretical risk between 80–100% in absence of surgery the mean reduction was 4.6±2.1%.

Conclusion

Urgent cardiac surgery is a protective factor of in-hospital mortality for all patients with left-sided IE but especially for those with intermediate risk.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Gerencia Regional de Salud, Junta de Castilla y Leόn

The 3 noes right-sided infective endocarditis: a unrecognized type of right-sided endocarditis

Introduction

The “3 noes right-sided infective endocarditis” (3no-RSIE: no left-sided, no drug users, no cardiac devices) was depicted for the first time more than a decade ago. We describe the largest series to date to characterize its clinical, microbiological, echocardiographic and prognostic profile.

Methods

Eight tertiary centers with surgical facilities participated in this study. Patients with right-sided endocarditis without left involvement, absence of antecedents of drug use and no intracardiac electronic devices were retrospectively included in a multipurpose database. A total of 53 variables were analysed in every patient. We performed a univariate analysis of in-hospital mortality to determine variables associated with worse prognosis.

Results

A total of 100 patients (mean age 54.1±20 years, 65% male) with definite 3no-RSIE were included (16.7% of all the right-sided endocarditis of the series). Most of the episodes were community-acquired (72%), congenital cardiopathies were frequent, fever was the main manifestation at admission (85%). The microbiological profile is led by Staphylococci spp. Vegetations were detected in 92% of the patients. Global in-hospital mortality was 19% (5.7% in patients operated and 26% in patients who received only medical treatment, p<0.001). Non community-acquired infection, diabetes mellitus, right heart failure, septic shock and acute renal failure were more common in patients who died.

Conclusions

The clinical profile of 3no-RSIE is closer to other types of RSIE than to LSIE, but mortality is higher than that reported on for other types of RSIE. Surgery plays an important role in improving outcome.

Funding Acknowledgement

Type of funding source: None

Performance of the heart team approach in daily clinical practice in high-risk patients with aortic stenosis

OBJECTIVE

The heart team (HT) approach plays a key role in selecting the optimal treatment strategy for patients with aortic stenosis (AS). However, little is known about the HT decision process and its impact on outcomes. The aim of this study was to identify the factors associated with the HT decision and evaluate clinical outcomes according to the treatment choice.

METHODS

The study included a total of 286 consecutive patients with AS referred for discussion in the weekly HT meeting in a cardiovascular institute over 2 years. Patients were stratified according to the selected therapeutic approach: medical treatment (MT), surgical (SAVR), or transcatheter (TAVR) aortic valve replacement. Baseline characteristics involved in making a therapeutic choice were identified and a decision-making tree was built using classification and regression tree methodology.

RESULTS

Based on HT discussion, 53 patients were assigned to SAVR, 210 to TAVR, and 23 to MT. Older patients (≥88 years old) were mainly assigned to TAVR or MT according to the logistic EuroSCORE (<or≥28, respectively). While among younger patients (<88 years), significant mitral regurgitation (≥grade III), frailty, Society of Thoracic Surgeons score, and estimated glomerular filtration rate were the most relevant factors influencing treatment allocation. One-year all-cause mortality was 16.6% in the invasive groups (TAVR = 17.2%, SAVR = 14.0%) and 68.7% in the MT arm.

CONCLUSION

The HT decision was determined by well-recognized risk factors that were used to define a treatment decision algorithm. Future studies with younger and lower-risk patients may identify new contributory factors that may alter the selection process and treatment choice.

Clinical outcomes of patients presenting with spontaneous coronary artery dissection versus takotsubo syndrome: a propensity score analysis

Background:

Spontaneous coronary artery dissection and takotsubo syndrome are non-atherosclerotic causes of acute coronary syndromes. They share clinical features including female predominance and frequent triggers. We compared the outcomes of patients with spontaneous coronary artery dissection and patients with takotsubo syndrome with similar clinical characteristics.

Methods:

Patients with spontaneous coronary artery dissection (n=81) or takotsubo syndrome (n=341) were 1:1 propensity matched according to age, sex, cardiovascular risk factors and clinical presentation. We compared baseline characteristics, effects on left ventricular function, and recurrence of major adverse cardiovascular events; defined as a composite of new hospitalisation for cardiac cause, clinical recurrence (spontaneous coronary artery dissection/takotsubo syndrome), myocardial infarction and death.

Results:

Propensity score yielded 78 pairs: 85% were women, whose average age was 55.3±12.6 years, 28% had two or more cardiovascular risk factors, 37% presented with ST-segment elevation and 5% presented with cardiogenic shock. In the spontaneous coronary artery dissection group, 50% (39/78) of cases involved the left anterior descending artery and 18% (14/78) underwent revascularisation. After a median follow-up of 5 years (interquartile range 2.4–5), major adverse cardiovascular events were significantly higher in the spontaneous coronary artery dissection group (18% (14/78) vs. 8% (6/78); hazard ratio 3.40, 95% confidence interval 1.2–9.4). This was mainly driven by early readmissions for cardiac causes (17% vs. 5%, P=0.007). Spontaneous coronary artery dissection was associated with higher peak values of creatinine kinase during admission (creatinine kinase/upper limit of normality 2.49 vs. 1.21, P&lt;0.001). Binary left ventricular systolic dysfunction was more prevalent in the takotsubo syndrome group (22% vs. 53%, P&lt;0.001), but no significant differences were noted at follow-up (6% vs. 1%, P=0.181).

Conclusions:

In this cohort of middle-aged predominantly female patients presenting with acute coronary syndromes, the diagnosis of spontaneous coronary artery dissection compared to takotsubo syndrome conferred a worse long-term clinical outcome, mainly driven by an increased risk of rehospitalisation for cardiac causes.

Circumflex Artery Arising From the Pulmonary Artery

Some coronary artery anomalies are associated with increased risk of sudden cardiac death and myocardial infarction in young patients. There are few data on the clinical and prognostic relevance of isolated origin of the left circumflex artery from the pulmonary artery, an extraordinarily rare variant of anomalous left coronary artery from the pulmonary artery. (Level of Difficulty: Intermediate.)

The ‘wait for symptoms’ strategy in asymptomatic severe aortic stenosis

Calcific aortic stenosis is a prevalent and worrisome healthcare problem. The therapeutic approach in asymptomatic aortic stenosis is not well established. We argue that the natural history of this disease is based on old incomplete studies with many limitations. Likewise, studies suggesting that replacement, either surgical or percutaneous, improves prognosis in asymptomatic patients with severe aortic stenosis have important drawbacks and do not support this strategy as the treatment of choice. Despite the lack of evidence, some groups recommend early valve replacement in patients with severe asymptomatic aortic stenosis. There are five ongoing randomised trials which will shed light on this topic. Our conclusion is that unless a randomised study changes the evidence, valve replacement cannot be recommended in asymptomatic patients with severe aortic stenosis.

Short-course antibiotic regimen compared to conventional antibiotic treatment for gram-positive cocci infective endocarditis: randomized clinical trial (SATIE)

Background

Most serious complications of infective endocarditis (IE) appear in the so-called “critical phase” of the disease, which represents the first days after diagnosis. The majority of patients overcoming the acute phase has a favorable outcome, yet they remain hospitalized for a long period of time mainly to complete antibiotic therapy. The major hypothesis of this trial is that in patients with clinically stable IE and adequate response to antibiotic treatment, without signs of persistent infection, periannular complications or metastatic foci, a shorter antibiotic time period would be as efficient and safe as the classic 4 to 6 weeks antibiotic regimen.

Methods

Multicenter, prospective, randomized, controlled open-label, phase IV clinical trial with a non-inferiority design to evaluate the efficacy of a short course (2 weeks) of parenteral antibiotic therapy compared with conventional antibiotic therapy (4–6 weeks).

Sample: patients with IE caused by gram-positive cocci, having received at least 10 days of conventional antibiotic treatment, and at least 7 days after surgery when indicated, without clinical, analytical, microbiological or echocardiographic signs of persistent infection. Estimated sample size: 298 patients. Intervention: Control group: standard duration antibiotic therapy, (4 to 6 weeks) according to ESC guidelines recommendations. Experimental group: short-course antibiotic therapy for 2 weeks. The incidence of the primary composite endpoint of all-cause mortality, unplanned cardiac surgery, symptomatic embolisms and relapses within 6 months after the inclusion in the study will be prospectively registered and compared.

Conclusions

SATIE will investigate whether a two weeks short-course of intravenous antibiotics in patients with IE caused by gram-positive cocci, without signs of persistent infection, is not inferior in safety and efficacy to conventional antibiotic treatment (4–6 weeks).

Trial registration

ClinicalTrials.gov Identifier: NCT04222257 (January 7, 2020).

EudraCT 2019–003358-10.

Diagnosing Aortic Intramural Hematoma: Current Perspectives

Aortic intramural hematoma (AIH) is an entity within the acute aortic syndrome. Combination of a priori probability, clinical history, laboratory blood test and imaging techniques are the basis for diagnosis of AIH. This review is focused on all aspects related to diagnosis of patients with AIH, from clinical to imaging and analytical.

Successful Conservative Treatment of a Large Infected Saphenous Graft Aneurysm: Usefulness of PET/CT

We report a case of a 75-year-old man with a medical history of coronary artery bypass graft surgery and a recent graft angioplasty, who presented to our emergency department with fever. An 18F-fluorodeoxyglucose positron emission tomography demonstrated a saphenous graft infected aneurysm, which was successfully treated conservatively with antibiotic therapy. (Level of Difficulty: Beginner.).

Contemporary epidemiology and outcomes in recurrent infective endocarditis

Objective

Recurrent infective endocarditis (IE) is a major complication of patients surviving a first episode of IE. This study sought to analyse the current state of recurrent IE in a large contemporary cohort.

Methods

1335 consecutive episodes of IE were recruited prospectively in three tertiary care centres in Spain between 1996 and 2015. Episodes were categorised into group I (n=1227), first-IE episode and group II (n=108), recurrent IE (8.1%). After excluding six patients, due to lack of relevant data, group II was subdivided into IIa (n=87), reinfection (different microorganism), and IIb (n=15), relapse (same microorganism within 6 months of the initial episode).

Results

The cumulative burden and incidence of recurrence was slightly lower in the second decade of the study (2006–2015) (7.17 vs 4.10 events/100 survivors and 7.51% vs 3.82, respectively). Patients with reinfections, compared with group I, were significantly younger, had a higher frequency of HIV infection, were more commonly intravenous drug users (IVDU) and prosthetic valve carriers, had less embolic complications and cardiac surgery, with similar in-hospital mortality. IVDU was found to be an independent predictor of reinfection (HR 3.92, 95% CI 1.86 to 8.28).

In the relapse IE group, prosthetic valve endocarditis (PVE) and periannular complications were more common. Among patients treated medically, those with PVE had a higher relapse incidence (4.82% vs 0.43% in native valve IE, p=0.018). Staphylococcus aureus and PVE were independent predictors of relapse (HR 3.14, 95% CI 1.11 to 8.86 and 3.19, 95% CI 1.13 to 9.00, respectively) and in-hospital-mortality was similar to group I. Three-year all-cause mortality was similar in recurrent episodes compared with single episodes.

Conclusion

Recurrent IE remains a frequent late complication. IVDU was associated with a fourfold increase in the risk of reinfection. PVE treated medically and infections caused by S. aureus increased the risk of relapse. In-hospital and long-term mortality was comparable among groups.

"A contemporary description of staphylococcus aureus prosthetic valve endocarditis. Differences according to the time elapsed from surgery"

Staphylococcus aureus prosthetic valve endocarditis (SAPVE) has a poor prognosis. There are no large series that accurately describe this entity.This is a retrospective observational study on a prospective cohort from 3 Spanish reference hospitals for cardiac surgery, including 78 definitive episodes of left SAPVE between 1996 and 2016.Fifty percent had a Charlson Index score >5; 53% were health care-related. Twenty percent did not present fever. Complications at diagnosis included: severe heart failure (HF, 29%), septic shock (SS, 17.9%), central nervous system abnormalities (19%), septic metastasis (4%). Hemorrhagic stroke was not higher in anticoagulated patients. Twenty-seven percent were methicilin-resistant SA (MRSA). Fifteen of 31 had positive valve culture; it was related to surgery within first 24 hours. At diagnosis, 69% had vegetation (>10 mm in 75%), 21.8% perianular extension, and 20% prosthetic dehiscence. Forty-eight percent had persistent bacteremia, related to nonsurgical treatment. Perianular extension progressed in 18%. Surgery was performed in 35 episodes (12 with stroke). Eleven uncomplicated episodes were managed with medical therapy, 8 survived. In-hospital mortality was 55%, higher in episodes with hemorrhagic stroke (77.8% vs 52.2%, odds ratio 3.2 [0.62-16.55]). Early SAPVE was nosocomial (92%), presented as severe HF (54%), patients were diagnosed and operated on early, 38% died. In intermediate SAPVE (9 weeks-1 year) diagnosis was delayed (24%), patients presented with constitutional syndrome (18%), renal failure (41%), and underwent surgery >72 hours after indication; 53% died. Late SAPVE (>1 year) was related with health care, diagnosis delay, and 60% of deceases.Left SAPVE frequently affected patients with comorbidity and health care contact. Complications at diagnosis and absence of fever were frequent. Presence of MRSA was high. Positive valve culture was related to early surgery. Paravalvular extension was frequent; vegetations were large, but its absence at diagnosis was common. Some uncomplicated SAPVE episodes were safety treated with medical therapy. Surgery was feasible in patients with stroke. Mortality was high. There were differences in some clinical characteristics and in evolution according to the time elapsed from valve replacement. Prognosis was better in early SAPVE.

Early surgery for acute-onset infective endocarditis

OBJECTIVES

Acute onset of infective endocarditis has been previously linked to the development of septic shock and a worse prognosis. The purpose of this study was to analyse the clinical features and in-hospital evolution of patients with acute-onset endocarditis as well as the potential role of early surgery in the treatment of these patients.

METHODS

From 1996 to 2014, 1053 consecutive patients with left-sided endocarditis were prospectively included. Patients were classified into 2 groups according to the clinical presentation: patients with acute-onset endocarditis (n = 491) and patients with non-acute endocarditis (n = 562). Acute-onset endocarditis was considered when the time between the appearance of symptoms and diagnosis was <15 days.

RESULTS

At admission, acute renal failure, septic shock and cerebral embolism predominated among patients with acute-onset endocarditis. Staphylococcus aureus was more frequently isolated in patients with an acute onset (27.7% vs 7.8% P < 0.001). During hospitalization, patients with acute onset developed systemic embolism and septic shock more frequently. Death was much more common in this group (42.7 vs 30.1%, P < 0.001). Paravalvular complications, nosocomial infection, heart failure, S. aureus and septic shock were predictors of mortality. Acute-onset presentation of endocarditis was strongly associated with increased mortality. Among patients with acute-onset endocarditis, early surgery, performed within the first 2 days after diagnosis, was associated with a 64% of reduction in mortality.

CONCLUSIONS

Patients with endocarditis and acute onset of symptoms are at high risk of septic in-hospital complications and mortality. Early surgery, performed within the first 2 days after diagnosis, plays a central role in the treatment of these patients.

Morphological characterization of vegetation by real-time three-dimensional transesophageal echocardiography in infective endocarditis: Prognostic impact

PURPOSE

Vegetation size is a prognostic predictor in infective endocarditis (IE) and guides surgical management. The aim of this study was to evaluate the accuracy of real-time 3-dimensional transesophageal echocardiography (RT3DTEE) compared to 2DTEE in the diagnosis and characterization of vegetation, as well as its potential clinical impact.

METHODS

Two hundred and three consecutive patients with IE were recruited (2009-2016) and retrospectively analyzed. Vegetation diameters and area from 68 patients were measured by 2DTEE and RT3DTEE at admission. The association between size and systemic embolisms was evaluated with logistic regression models. Differences in the discriminative power for the best dimensions' cutoff points were assessed by comparing the area under the ROC curves (AUC).

RESULTS

Vegetation size and area were larger by RT3DTEE (P < 0.001) than by 2DTEE, and RT3DTEE was especially relevant in the characterization of nonfiliform vegetation, Morphology was strongly associated with friability, being sessile vegetation less likely to embolize, compared to filiform and raceme-shaped ones (15.4% vs 46% vs 50%). Major diameter by RT3DTEE had better embolic predictive performance than 2DTEE (AUC 0.76 [0.57-0.89] vs 0.71 [0.53-0.86]; P = 0.611). The best cutoff points associated with embolic events during the infection were 17 mm for RT3DTEE and 15 mm for 2DTEE. Based exclusively on vegetation size, the proportion of patients meeting a surgical indication according to current guidelines is higher using RT3DTEE.

CONCLUSIONS

RT3DTEE allows a better characterization of IE vegetation than 2DTEE, what may have a clinical impact on surgical management and also prognostic due to a more accurate prediction of embolic risk.

Surgery changes prognosis in infective endocarditis: The importance of post-surgical clinical evolution

BACKGROUND

Left-sided infective endocarditis (LSIE) bears a grim prognosis and surgery is needed in more than half of the patients to improve survival. Our hypothesis has been that clinical complications developing after surgery impact prognosis.

METHODS

Among 1075 consecutive episodes of LSIE, 654 (60.7%) underwent cardiac surgery. Of them, 41 patients (6.3%) died the same day of surgery, 112 (17.2%) died after the first day of surgery during hospital stay and 500 (76.5%) were successfully discharged. We compared the last two groups and performed a multivariable analysis of in-hospital mortality.

RESULTS

Age (OR 1.02, 95% CI 1.01-1.04), periannular complications (OR 1.9, 95% CI 1.2-3.2) renal failure after surgery (OR 2.4, 95% CI 1.3-4.4) but not before surgery, and septic shock after surgery (OR 9.6, 95% CI 5.4-17.1) but not before surgery are predictive of in-hospital death among LSIE patients who underwent cardiac surgery.

CONCLUSION

A thorough clinical assessment with prognostic purposes in infective endocarditis after surgery is mandatory. In-hospital mortality of patients with infective endocarditis who undergo surgery depends mainly on the clinical evolution after surgery.