Native valve right sided infective endocarditis

A surgical odyssey: Conquering a titanic tricuspid vegetation reaching into the superior vena cava - A case report

INTRODUCTION

Right-sided infective endocarditis, particularly of the tricuspid valve, is rare and challenging to diagnose, often presenting with nonspecific symptoms, and associated with high mortality rates. This case underscores the complexities in managing such conditions and the importance of early diagnosis and multidisciplinary intervention.

CASE PRESENTATION

This case study details the medical history of a 34-year-old woman who had a background of intravenous drug abuse. She subsequently developed a fungal tricuspid valve endocarditis, leading to the formation of vegetation that extended into the superior vena cava. The mass measured 15 × 3 cm upon surgical removal.

DISCUSSION

Right-sided infective endocarditis is rare, comprising only 5-10 % of cases, with tricuspid valve endocarditis being even rarer. Damage to the endothelium facilitates bacterial attachment, especially in IV drug users, with Staphylococcus aureus being common. Fungal endocarditis is rare but deadly, with high mortality. Diagnosis relies on the modified Duke criteria, including microbiological and imaging evidence. Major complications affect both valvular and systemic areas. Treatment p1rimarily involves IV antibiotics, but surgery is needed for persistent infections or severe complications.

CONCLUSION

This case underscores the critical importance of early diagnosis and intervention in managing right-sided infective endocarditis, especially with a fungal pathology and in patients with complex medical histories.

Isolated pulmonary valve endocarditis in a pediatric patient with down syndrome

BACKGROUND

Isolated pulmonary valve endocarditis (IPE) accounts for less than 2% of all infective endocarditis patients. It is commonly associated with several predisposing factors, including intravenous drug use (IVDU) and congenital heart disease. The most common causative pathogens of IPE are Staphylococcus aureus and Streptococcus viridans. We report a Down's syndrome patient with IPE and with no standard risk factors caused by the rare pathogen Acinetobacter spp. This led to respiratory failure and systemic infection due to septic pulmonary emboli. Early elective surgery was decided upon as the patient was no longer responding to medical therapy, and his clinical condition was worsening over time.

CASE PRESENTATION

A 15-year-old male with Down syndrome and no underlying heart defect presented with a 3-month history of episodic fever, nausea, vomiting, and diarrhea. Transthoracic echocardiography (TTE) revealed large vegetation on the pulmonary valve leaflet, another mobile mass at the pulmonary artery bifurcation, and severe pulmonary regurgitation. Serial blood cultures isolated Acinetobacter spp. Despite initial antibiotic therapy, the patient continued to have sepsis, unresolved vegetations, and developed life-threatening complications and respiratory distress, which convinced us to perform a pulmonary valve replacement surgery with a homograft. After surgery, the patient recovered and was discharged on the ninth postoperative day (POD).

CONCLUSION

This report highlights IPE's diagnostic and therapeutic challenges, alongside the importance of a comprehensive cardiopulmonary workup in patients with unexplained fever, sepsis, and pulmonary symptoms, even without typical risk factors. Based on the patient's aggravating condition despite medical treatment, early surgical intervention and pulmonary valve replacement were deemed crucial. However, there still needs to be a definitive guideline on when and how surgery should be performed in patients with complicated IPE, especially in pediatric patients.

A Case Report of Acute Infective Endocarditis Caused by Aggregatibacter aphrophilus Involving the Tricuspid Valve

We report a case of a 16-year-old male with tricuspid valve infective endocarditis caused by Aggregatibacter aphrophilus and complicated by pulmonary septic embolisms. Multiple antimicrobial therapy was unsuccessful and surgical management was required. In this report, the authors highlight the importance of a high index of suspicion regarding the diagnosis of endocarditis and its possible complications.

Prosthetic Joint Infection Complicated by Staphylococcus aureus Bacteremia and Tricuspid Valve Infective Endocarditis: A Novel Case Report

Prosthetic joint infection (PJI) is defined as an infection involving the prosthesis and surrounding soft tissue and bone that is a difficult complication to treat and is a common cause of revision total joint arthroplasty (TJA). Bacteremia, sepsis, and infective endocarditis (IE) are rare complications in patients who have undergone TJA. We report a rare case where a patient presented with purulent discharge from the left knee joint post-TJA concerning PJI and was found to have methicillin-sensitive Staphylococcus aureus bacteremia, tricuspid valve endocarditis, and septic pulmonary emboli. The patient underwent irrigation, debridement, and a spacer device placement in the affected knee joint for PJI and was medically treated for IE with six weeks of antibiotic therapy. The patient successfully recovered and was discharged to a rehabilitation facility. We conclude that PJI and IE secondary to TJA are very rare, but given the high morbidity and mortality, if diagnosis and treatment are delayed, physicians should always remain vigilant for these complications in the appropriate clinical context.

A Typical Case of Atypical Disease: "Three Noes" Infective Endocarditis

Recognizing typical presentations of atypical cases is essential to reduce diagnostic errors and achieve better diagnoses. To better understand this, we report a typical case of "three noes" infective endocarditis (no left-sided, no intravenous drug use, and no intracardiac devices) with some different characteristics from well-known infective endocarditis. A 16-year-old boy with a history of atopic dermatitis presented with a one-month history of intermittent fever and shaking chills. The patient became afebrile with oral antibiotics, and initial investigations did not detect any evidence of bacterial infection, including heart murmurs and peripheral embolic manifestations. However, his symptoms relapsed one week after the cessation of antibiotics. A repeated workup revealed tricuspid valve infective endocarditis due to methicillin-susceptible Staphylococcus aureus. The relationship between atopic dermatitis and infective dermatitis has been reported in some literature, and clinicians should consider three noes infective endocarditis in patients with atopic dermatitis presenting with fever and unremarkable physical examination.

Pulmonary Valve Endocarditis: Always Look on the (B)right Side!

•PV endocarditis is a rare entity. •Severe PR has a characteristic spectral profile on continuous-wave Doppler. •Transesophageal echocardiography can help to visualize the PV.

18F-fluorodeoxyglucose positron emission tomography/CT in the diagnosis of right-sided endocarditis in children and adults with infective endocarditis

OBJECTIVE

Infectious endocarditis poses a diagnostic challenge due to its highly variable clinical presentation. To establish a definitive diagnosis, different imaging modalities are essential. In recent years, positron emission tomography/CT has gained increasing significance in diagnosing infective endocarditis; however, its application in the pediatric age group remains limited. This study encompasses patients definitively or potentially diagnosed with infectious endocarditis at our institution from 2018 to 2023.

METHODS

A total of 29 patients underwent 18F-fluorodeoxyglucose positron emission tomography/CT examinations, with 19 of them presenting with right-sided infective endocarditis.

RESULTS

Evidence consistent with infective endocarditis was observed in 18 (94.7%) of the patients. Pulmonary septic embolism was identified in 15 (78.9%) cases, and splenic involvement was noted in 12 (57.8%) cases. Transthoracic/transesophageal echocardiography failed to reveal vegetation or provided uncertain results in six patients, whereas fluorodeoxyglucose-positron emission tomography-CT exhibited involvement. Subsequently, the diagnosis of infective endocarditis was confirmed post-surgery based on the fluorodeoxyglucose-positron emission tomography-CT findings.

CONCLUSION

Our results, along with our clinical experience, demonstrate that fluorodeoxyglucose-positron emission tomography-CT is a safe and viable method for diagnosing right-sided endocarditis, which is often challenging to visualize using echocardiography.

Clinical characteristics and risk factors for right-sided infective endocarditis in Korea: a 12-year retrospective cohort study

Right-sided infective endocarditis (RSIE) is less common than left-sided infective endocarditis (LSIE) and exhibits distinct epidemiological, clinical, and microbiological characteristics. Previous studies have focused primarily on RSIE in patients with intravenous drug use. We investigated the characteristics and risk factors for RSIE in an area where intravenous drug use is uncommon. A retrospective cohort study was conducted at a tertiary hospital in South Korea. Patients diagnosed with infective endocarditis between November 2005 and August 2017 were categorized into LSIE and RSIE groups. Of the 406 patients, 365 (89.9%) had LSIE and 41 (10.1%) had RSIE. The mortality rates were 31.7% in the RSIE group and 31.5% in the LSIE group (P = 0.860). Patients with RSIE had a higher prevalence of infection with Staphylococcus aureus (29.3% vs. 13.7%, P = 0.016), coagulase-negative staphylococci (17.1% vs. 6.0%, P = 0.022), and gram-negative bacilli other than HACEK (12.2% vs. 2.2%, P = 0.003). Younger age (adjusted odds ratio [aOR] 0.97, 95% confidence interval [CI] 0.95-0.99, P = 0.006), implanted cardiac devices (aOR 37.75, 95% CI 11.63-141.64, P ≤ 0.001), and central venous catheterization  (aOR 4.25, 95%  CI 1.14-15.55, P = 0.029) were independent risk factors for RSIE. Treatment strategies that consider the epidemiologic and microbiologic characteristics of RSIE are warranted.

Tricuspid valve repair and replacement for infective endocarditis

Infective endocarditis represents a challenging and life-threatening clinical condition affecting native and prosthetic heart valves, endocardium, and implanted cardiac devices. Right-sided infective endocarditis account for approximately 5-10% of all infective endocarditis and are often associated with intravenous drug use, intracardiac devices, central venous catheters, and congenital heart disease. The tricuspid valve is involved in 90% of right-side infective endocarditis. The primary treatment of tricuspid valve infective endocarditis is based on long-term intravenous antibiotics. When surgery is required, different interventions have been proposed, ranging from valvectomy to various types of valve repair to complete replacement of the valve. Percutaneous removal of vegetations using the AngioVac system has also been proposed in these patients. The aim of this narrative review is to provide an overview of the current surgical options and to discuss the results of the different surgical strategies in patients with tricuspid valve infective endocarditis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01650-0.

Minimally invasive procedures for right side infective endocarditis: A targeted literature review

INTRODUCTION

Right-side infective endocarditis (RSIE) is caused by microorganisms and develops into intracardiac and extracardiac complications with high in-hospital and 1-year mortality. Treatments involve antibiotic and surgical intervention. However, those presenting with extremes e.g. heart failure, or septic shock who are not ideal candidates for conventional medical therapy might benefit from minimally invasive procedures.

OBJECTIVE

This review summarizes existing observational studies that reported minimally invasive procedures to debulk vegetation due to infective endocarditis either on valve or cardiac implantable electronic devices.

METHODS

A targeted literature review was conducted to identify studies published in PubMed/MEDLINE, EMBASE, and Cochrane Central Database from January 1, 2015 to June 5, 2023. The efficacy and/or effectiveness of minimally invasive procedural interventions to debulk vegetation due to RSIE were summarized following PRISMA guidelines.

RESULTS

A total of 11 studies with 208 RSIE patients were included. There were 9 studies that assessed the effectiveness of the AngioVac system and 2 assessed the Penumbra system. Overall procedure success rate was 87.9%. Among 8 studies that reported index hospitalization, 4 studies reported no death, while the other 4 studies reported 10 deaths.

CONCLUSIONS

This study demonstrates that multiple systems can provide minimally invasive procedure options for patients with RSIE with high procedural success. However, there are mixed results regarding complications and mortality rates. Further large cohort studies or randomized clinical trials are warranted to assess and/or compare the efficacy and safety of these systems.

Pylephlebitis and Right-Sided Endocarditis: A Rare Complication of an Intra-abdominal Infection

Right-sided infective endocarditis is less common than left-sided endocarditis and can be a difficult clinical diagnosis. The presence of intracardiac devices is a major risk factor. The presentation is less clear than left-sided forms because of the presence of respiratory symptoms and the absence of systemic embolization. Pylephlebitis, or septic thrombosis of the portal vein, is a serious infectious condition that often delays diagnosis. It is a complication of intraabdominal or pelvic infections. Streptococcus gallolyticus (S. gallolyticus) can cause infective endocarditis and is associated with colon neoplasia and hepatobiliary disease. In this case report, we describe the case of a 76-year-old male with a history of rectal adenocarcinoma who presented with different episodes of fever of unknown origin (FUO), one of which occurred after pacemaker implantation. Ultimately, he was diagnosed with S. gallolyticus-mediated tricuspid valve endocarditis with underlying pylephlebitis. Investigations did not show evidence of pacemaker lead endocarditis.

A Large Tricuspid Subvalvular Apparatus Infective Endocarditis Undetected by Transthoracic Echocardiography

A 39-year-old male with a history of intravenous drug use (IVDU) and no significant cardiovascular disease was admitted to the ICU for management of septic shock and acute hypoxic respiratory failure secondary to septic pulmonary emboli. Due to a high clinical suspicion for right-sided infective endocarditis (IE), he received a transthoracic echocardiogram (TTE), which did not reveal any vegetations. However, a transesophageal echocardiogram (TEE) was subsequently performed; this showed a large 2.4 cm vegetation in the septal aspect of the tricuspid valve (TV) subvalvular apparatus. He urgently underwent surgical removal of the vegetation and repair of the TV. Postoperatively, he clinically recovered with appropriate antibiotic therapy. TEE is the ideal imaging modality in evaluation for IE, but a minimally invasive TTE is often performed first. This case highlights a highly unusual anatomic location of IE, which harbored a large vegetation undetected by TTE. In patients without cardiac devices or non-native valves, an urgent TEE remains diagnostically essential if there is a high clinical suspicion for right-sided IE, even if a TTE shows no evidence of IE.

Percutaneous mechanical aspiration in patients with right-sided infective endocarditis: An analysis of the national inpatient sample database-2016-2020

BACKGROUND

Given the challenges of conventional therapies in managing right-sided infective endocarditis (RSIE), percutaneous mechanical aspiration (PMA) of vegetations has emerged as a novel treatment option. Data on trends, characteristics, and outcomes of PMA, however, have largely been limited to case reports and case series.

AIMS

The aim of the current investigation was to provide a descriptive analysis of PMA in the United States and to profile the frequency of PMA with a temporal analysis and the patient cohort.

METHODS

The International Classification of Diseases, 10th Revision codes were used to identify patients with RSIE in the national (nationwide) inpatient sample (NIS) database between 2016 and 2020. The clinical characteristics and temporal trends of RSIE hospitalizations in patients who underwent PMA was profiled.

RESULTS

An estimated 117,955 RSIE-related hospital admissions in the United States over the 5-year study period were estimated and 1675 of them included PMA. Remarkably, the rate of PMA for RSIE increased 4.7-fold from 2016 (0.56%) to 2020 (2.62%). Patients identified with RSIE who had undergone PMA were young (medial age 36.5 years) and had few comorbid conditions (median Charlson Comorbidity Index, 0.6). Of note, 36.1% of patients had a history of hepatitis C infection, while only 9.9% of patients had a cardiovascular implantable electronic device. Staphylococcus aureus was the predominant (61.8%) pathogen. Concomitant transvenous lead extraction and cardiac valve surgery during the PMA hospitalization were performed in 18.2% and 8.4% of admissions, respectively. The median hospital stay was 19.0 days, with 6.0% in-hospital mortality.

CONCLUSIONS

The marked increase in the number of PMA procedures in the United States suggests that this novel treatment option has been embraced as a useful tool in select cases of RSIE. More work is needed to better define indications for the procedure and its efficacy and safety.

Management of isolated native tricuspid valve infective endocarditis by a multidisciplinary program: a single-center retrospective cohort study

Background

Isolated native tricuspid valve infective endocarditis remains a challenging disease to treat given the large number of patients with substance use disorder. There is limited data on the optimal treatment strategy and the impact of a multidisciplinary endocarditis program on outcomes for this population.

Objectives

To assess the clinical outcomes associated with management of native tricuspid valve infective endocarditis by a multidisciplinary team.

Design

Single-center, retrospective cohort study.

Methods

Patient cases were identified from the registry of the institutional multidisciplinary endocarditis team. Patients with left-sided endocarditis, multivalvular endocarditis, prosthetic tricuspid valves and cardiac implantable electronic devices were excluded.

Results

Between September 7th, 2021 and February 1st, 2024 72 consecutive patients with isolated native tricuspid valve infective endocarditis were identified. Sixty-six (91.7%) patients were managed medically. Five patients underwent percutaneous mechanical aspiration of tricuspid valve vegetations and one patient underwent tricuspid valve replacement during the index hospitalization. In-hospital mortality was 1.4% and 90-day mortality was 2.8%. Nineteen (26.4%) patients discharged before medically advised and 25% were re-admitted within 30 days. Ten (13.9%) patients underwent elective tricuspid valve replacements after outpatient follow-up.

Conclusion

Among 72 patients with isolated native tricuspid valve infective endocarditis managed by a multidisciplinary endocarditis program over a 2.5-year period, in-hospital, 90-day mortality and 1-year mortality were very low despite low rates of percutaneous mechanical aspiration and tricuspid valve surgery. Multidisciplinary follow-up can lead to elective tricuspid valve surgery in a delayed fashion.

IgA-Dominant Staphylococcus-Associated Glomerulonephritis: An Uncommon Complication of Intravenous Drug Use

A 24-year-old female with a history of intravenous heroin use presented with two weeks of chills, myalgias, and cough and was found to be in acute hypoxemic respiratory failure. Subsequent workup revealed the presence of bilateral septic pulmonary emboli and tricuspid valve endocarditis. Several weeks into her hospitalization, she developed periorbital edema and laboratory testing revealed she had developed acute renal failure and nephrotic range proteinuria. A renal biopsy confirmed the diagnosis of IgA-dominant Staphylococcus-associated glomerulonephritis (IgA-SAGN). Early recognition of this newly recognized variant of glomerulonephritis is paramount, as improper treatment may lead to catastrophic consequences.

Scoping review of percutaneous mechanical aspiration for valvular and cardiac implantable electronic device infective endocarditis

BACKGROUND

Percutaneous mechanical aspiration (PMA) of intravascular vegetations is a novel strategy for management of patients with infective endocarditis (IE) who are at high risk of poor outcomes with conventional cardiac surgery. However, clear indications for its use as well as patient outcomes are largely unknown.

OBJECTIVES

To conduct a scoping review of the literature to summarize patient characteristics and outcomes of those undergoing PMA for management of IE.

METHODS

Two independent reviewers screened abstracts and full text for inclusion and independently extracted data.

DATA SOURCES

MEDLINE, Embase, and Web of Science.

STUDY ELIGIBILITY CRITERIA

Studies published until February 21, 2023, describing the use of PMA for management of patients with cardiac implantable electronic device (CIED) or valvular IE were included.

ASSESSMENT OF RISK OF BIAS

As this was a scoping review, risk of bias assessment was not performed.

METHODS OF DATA SYNTHESIS

Descriptive data was reported.

RESULTS

We identified 2252 titles, of which 1442 abstracts were screened, and 125 full text articles were reviewed for inclusion. Fifty-one studies, describing a total of 294 patients who underwent PMA for IE were included in our review. Over 50% (152/294) of patients underwent PMA to debulk cardiac implantable electronic device lead vegetations prior to extraction (152/294), and 38.8% (114/294) of patients had a history of drug use. Patient outcomes were inconsistently reported, but few had procedural complications, and all-cause in-hospital mortality was 6.5% (19/294).

CONCLUSIONS

While PMA is a promising advance in the care of patients with IE, higher quality data regarding patient outcomes are needed to better inform the use of this procedure.

Infective endocarditis of a forgotten valve

A 62-years-old man with interventricular communication was admitted to the hospital with a 6-month history of constitutional symptoms. The patient was feverish and a grade III/VI continuous murmur was noted in all precordium. Patient’s blood analysis showed elevation of inflammatory markers and bacteriaemia caused by Granulicatella adiacens. Transoesophageal echocardiogram diagnosed infective endocarditis of the aortic valve. The patient completed 3 weeks of antibiotic therapy and was submitted to aortic valve replacement and correction of the interventricular communication. Before hospital discharge, routine transthoracic echocardiogram was done and a pulmonary valve vegetation measuring 6x7 mm, not previously described, was noted, as well as de novo severe pulmonary valve insufficiency. The surgical risk was very high in this patient. Antibiotic therapy was extended and the patient was maintained under close follow-up in appointments. The patient remained asymptomatic and clinically stable.

Clinical outcomes of severe tricuspid valve infective endocarditis related to intravenous drug abuse - a case series

BACKGROUND

Right-sided infective endocarditis (IE) related to intravenous drug use (IVDU) can follow an acute fulminant course. However, there is limited information on its longer-term clinical outcomes.

AIM AND METHODS

We assessed a cohort of consecutive patients who presented with IVDU complicated by severe tricuspid valve regurgitation to determine their presentation, treatment, and long-term outcomes. In this study, severe tricuspid regurgitation (TR) was defined by the European Association of Cardiovascular Imaging criteria at initial presentation to the hospital.

RESULTS

Thirty-three patients with a mean age of 35 ± 18 years (72% males) presented with IVDU associated with severe TR. At the initial presentation, 15 patients were in septic shock and required inotropes. 26 patients had septic pulmonary emboli; 10 patients had associated metastatic systemic sites of infection of which 5 patients had central nervous system (CNS) involvement. Three patients were in disseminated intravascular coagulation (DIC) and 1 patient had multi-organ failure (MOF), but not requiring dialysis or mechanical ventilation. Most patients had large tricuspid valve vegetations of >20mm. Eleven patients underwent surgery with 18% perioperative mortality. The Median follow-up was 6.4 years (0.5-11.4). Recurrent IE occurred in one-third of patients, the overall incidence of heart failure and Atrial fibrillation (AF) on follow-up was low in all 3 groups. Five-year survival was 94%.

CONCLUSION

Acute severe TR following associated endocarditis IVDU results in a fulminant initial presentation, but a longer-term prognosis is good with surgical and medical treatment.

Transesophageal Echocardiography–Guided Percutaneous Aspiration of a Large Tricuspid Valve Vegetation in a Patient with Infective Endocarditis

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Right-sided IE is associated with IVDU.

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Percutaneous debulking of TV vegetations can be a therapeutic option.

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TEE can help guide debulking.

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TEE can be used to monitor for and prevent complications.

Machine Learning-Based Risk Model for Predicting Early Mortality After Surgery for Infective Endocarditis

Background The early mortality after surgery for infective endocarditis is high. Although risk models help identify patients at high risk, most current scoring systems are inaccurate or inconvenient. The objective of this study was to construct an accurate and easy-to-use prediction model to identify patients at high risk of early mortality after surgery for infective endocarditis. Methods and Results A total of 476 consecutive patients with infective endocarditis who underwent surgery at 2 centers were included. The development cohort consisted of 276 patients. Eight variables were selected from 89 potential predictors as input of the XGBoost model to train the prediction model, including platelet count, serum albumin, current heart failure, urine occult blood ≥(++), diastolic dysfunction, multiple valve involvement, tricuspid valve involvement, and vegetation >10 mm. The completed prediction model was tested in 2 separate cohorts for internal and external validation. The internal test cohort consisted of 125 patients independent of the development cohort, and the external test cohort consisted of 75 patients from another center. In the internal test cohort, the area under the curve was 0.813 (95% CI, 0.670-0.933) and in the external test cohort the area under the curve was 0.812 (95% CI, 0.606-0.956). The area under the curve was significantly higher than that of other ensemble learning models, logistic regression model, and European System for Cardiac Operative Risk Evaluation II (all, P<0.01). This model was used to develop an online, open-access calculator (http://42.240.140.58:1808/). Conclusions We constructed and validated an accurate and robust machine learning-based risk model to predict early mortality after surgery for infective endocarditis, which may help clinical decision-making and improve outcomes.

A novel technique for the percutaneous removal of tricuspid valve vegetations utilizing the Inari Flowtriever System

Right-sided infective endocarditis is a common entity for which surgical intervention is frequently high-risk. Considering its invasive nature, potential complications, and challenging patient population, a less invasive endovascular option is desirable. The previous series have demonstrated the feasibility of percutaneous therapy for tricuspid valve (TV) vegetation utilizing a filter-based bypass circuit. However, the limited availability of a specialized team, resources, procedural complexity, and large bore sheath size restrict the broad adoption of this technique. The Inari FlowTriever System (Inari Medical) is an endovascular, catheter-based, aspiration, and mechanical thrombectomy system indicated for the removal of large-volume venous thrombus and pulmonary emboli. Independent of anesthesia, perfusion, or advanced imaging, this device's characteristics uniquely improve the operator's ability to safely remove unwanted debris from complex anatomy. This report describes the first, utilization of the Inari FlowTriever System for the removal of massive and inoperable TV vegetation.

Paradoxical embolisation in right-sided infective endocarditis and patent foramen ovale

Intravenous drug use (IVDU) is a growing public health crisis worldwide. A known complication of IVDU is right-sided infective endocarditis (RSIE) involving the tricuspid valve. As the tricuspid valve is burdened with infectious vegetations, it becomes a potential source of pulmonary and, very rarely, paradoxical systemic emboli. We report two patients with RSIE involving the tricuspid valve presenting with acute change in mental status. Subsequent imaging demonstrated embolisation to the brain in the setting of elevated right atrial pressures and the presence of a patent foramen ovale (PFO) with right-to-left shunting. We employed a strategy of percutaneous closure of PFO, to prevent further embolisation, as a successful bridge to definitive surgical management of RSIE. We emphasise that clinicians should evaluate for intracardiac shunting and pursue transesophageal echocardiography when encountering systemic emboli of unknown origin, particularly in patients with RSIE.

Between a Rock and a Hard Place: Percutaneous Aspiration and Debulking for Tricuspid Valve Endocarditis

Right-sided infective endocarditis (IE) constitutes about 10% of total IE cases. Of these, tricuspid endocarditis comprises about 90% of all right-sided IE cases with intravenous drug use (IVDU) as its strongest risk factor. In patients with larger vegetations (>20 mm) or with persistent bacteremia, surgical intervention is often the standard of care. With FDA approval in 2014 and limited cases with regards to its application in tricuspid endocarditis, AngioVac (AngioDynamics, Latham, NY) has been used as a less invasive, off-label, bridging agent for tricuspid IE treatment. We present a case of a 40-year-old man with a past medical history of IVDU who presented with tricuspid endocarditis. His blood cultures were positive for methicillin-susceptible Staphylococcus aureus bacteremia. A transthoracic echocardiogram showed a 2.7 x 1.1 cm vegetation of the tricuspid valve. The patient was thought to be a poor surgical candidate for multifactorial reasons including patient preference, hemodynamic instability, and a hospital course that was complicated by septic emboli and infectious glomerulonephritis. The patient was unable to clear blood cultures despite appropriate antibiotic therapy. He subsequently underwent an AngioVac procedure with removal of the vegetation from his tricuspid valve achieving adequate source control, clear blood cultures, and resolution of endocarditis.

As this case illustrates, AngioVac should be considered an effective alternative to surgical intervention in tricuspid endocarditis. Further research and awareness of the utility of AngioVac in right-sided endocarditis are warranted and should be conducted.

Neisseria gonorrhoeae infective endocarditis

We present a case of endocarditis secondary to disseminated Neisseria gonorrhoeae infection affecting the native tricuspid valve. After a thorough workup, our patient was treated conservatively with appropriate intravenous antibiotic therapy for 6 weeks. A follow-up echocardiogram showed resolution of the vegetation without any residual valvular involvement. Literature review reveals 99 cases of infective endocarditis which occurred secondary to N. gonorrhoeae infection, of which, only 4 cases (6%) affected the tricuspid valve. Through this case report, we highlight the importance of thorough history taking including a sexual and social history, as well as careful recognition of the clinical signs, which helped us reach this uncommon diagnosis while always maintaining a high clinical suspicion of rare causes of endocarditis.

An Interesting Case of Serratia Endocarditis in a Patient With Chronic Myeloid Leukemia

Serratia is a rare cause of infective endocarditis (IE) and usually occurs in patients with underlying risk factors, such as intravenous (IV) drug use, and human immunodeficiency virus patients. Gram-negative bacteria endocarditis is associated with high mortality when it involves the left side of the heart and often requires surgical intervention in addition to medical treatment. Although most gram-negative endocarditis cases are hospital-acquired, community cases have also been reported. Here, we present a case of Serratia endocarditis in an individual who was later diagnosed with chronic myeloid leukemia (CML) during the same hospitalization. The patient was treated with IV meropenem and started on targeted therapy for CML. CML is presumed to have likely predisposed the patient to bacteremia and IE.

Novel intracardiac echocardiography-guided catheter-based removal of inoperable tricuspid valve vegetation

With the ongoing intravenous drug abuse (IVDA) epidemic, the number of IVDA patients with infective endocarditis is increasing. These cases are often characterized by large vegetations complicated by valvular dysfunction, heart failure, and recurrent septic pulmonary emboli demanding surgical intervention. Latter cannot be offered in a good proportion of the patients due to challenging medical and social complexities. Hence, AngioVac system has been used as an alternative therapy; however, it is associated with high procedural mortality. In this document, we describe in detail the successful treatment of a case of large tricuspid valve vegetation, with prohibitive risk for surgery, using a percutaneous catheter-based system, the Triever aspiration catheter with FLEX technology, with the guidance of intracardiac echocardiogram.

Isolated Enterococcus faecalis pulmonary valve endocarditis without precipitating risk factors: A case report describing delayed need for surgery three years after antimicrobial therapy

INTRODUCTION AND IMPORTANCE

Isolated Enterococcus faecalis pulmonary valve endocarditis (PVE) without precipitating risk factors is exceeding rare, as fewer than ten cases have been published in the literature, most of which did not require surgical intervention.

CASE PRESENTATION

An elderly individual presented for evaluation of dyspnea, fatigue, dizziness, weight loss, and a low-grade fever. The patient denied intravenous drug abuse, blood-borne viral infection, cardiac trauma, congenital heart disease, and immunocompromise. Echocardiography identified a large vegetation on the right pulmonary valve leaflet consistent with isolated PVE. Blood cultures grew E. faecalis. Computed tomography failed to reveal an infectious source. The patient completed a six-week course of antibiotics and was followed with serial echocardiography for three years, but subsequently developed severe pulmonic insufficiency and right heart failure necessitating pulmonary valve replacement.

CLINICAL DISCUSSION

Isolated PVE is responsible for less than 2.0% of all cases of infective endocarditis. The vast majority of reported cases are associated with risk factors and are caused by gram-positive organisms including Staphylococcus species and Streptococcus viridans. Echocardiography identifies most cases of isolated PVE. Septic embolization of vegetation fragments to lung parenchyma is common. Surgery is reserved for patients who are unresponsive to antibiotics or those who develop severe pulmonary insufficiency with symptoms of right heart failure, as seen here.

CONCLUSION

We present an unusual case of isolated E. faecalis PVE without known risk factors that required pulmonary valve replacement three years after antimicrobial therapy.

Right-Side Endocarditis: A Typical Presentation in an Atypical Patient

Right-side endocarditis (RSE) is a well-defined clinical entity, rarer than left-side endocarditis. Known risk factors include intravenous drug use or the presence of medical devices. The most frequently affected valve is the tricuspid valve. In most cases, medical treatment is enough. Surgical treatment is reserved for failed medical therapy or in the presence of large vegetations. Although there is a high recurrence rate in intravenous drug users (IDU), RSE has a generally good prognosis. We present the case of a 70-year-old male with no known previous diseases other than alcohol abuse. He was admitted with fever, cough, hemoptysis and a weight loss of 8 kg in two months. Chest X-ray revealed two images of condensation, one in the right pulmonary base and another in the superior right lobe. A computerized tomography of the thorax revealed a subsegmental pulmonary embolism. The patient refused hospitalization and was discharged medicated with levofloxacin and apixaban. In ambulatory, there was a decrease in size of the lesions but with a new lesion in the right hemithorax. Two months after the first episode, the patient is admitted with the same symptoms. The transthoracic echocardiogram showed a 20cm vegetation in the tricuspid valve. He was admitted to the hospital and received treatment with penicillin and gentamicin after isolation of Streptococcus mitis in the blood cultures. Surgical treatment was needed after a weak response to antibiotics, with a good evolution.

A case of percutaneous tricuspid valve infective endocarditis vegetation debulking using the AngioJet rheolytic catheter system-A novel therapeutic use

In patients with fulminant tricuspid valve infective endocarditis precluded from cardiothoracic intervention based on comorbidities or clinical status, percutaneous vegetation debulking utilizing the AngioJet rheolytic catheter system appears a viable rescue option to achieve source control.

Role of echocardiography in uncomplicated Staphylococcus aureus catheter-related bloodstream infections

Uncomplicated bacteremia and catheter-related bloodstream infection (CRBSI) are frequently suggested as factors associated with low risk of infective endocarditis in Staphylococcus aureus bacteremia (SAB). Nevertheless, guidelines recommend that echocardiography in all patients with SAB. We evaluated the effects of echocardiography on patient outcomes. Patients with uncomplicated S. aureus CRBSI were retrospectively identified between January 2013 and June 2018 at a 1950-bed, tertiary-care university hospital. Treatment failure was defined as any case of relapse or all-cause death within 90 days. Of 890 SAB patients, 95 with uncomplicated S. aureus CRBSI were included. Thirty-two patients underwent echocardiography within 30 days of their first positive blood culture. Two patients who underwent echocardiography revealed right-sided infective endocarditis. One patient who did not undergo echocardiography experienced recurrent SAB (peripheral CRBSI) 85 days after his first positive blood culture. There were no SAB-related deaths. The Kaplan-Meier curves of treatment failure showed no significant differences between patients who did and did not undergo echocardiography (P = .77). In multivariable analysis, risk factors for treatment failure were liver cirrhosis (hazard ratio: 9.60; 95% confidence interval: 2.13-43.33; P = .003) and other prostheses (hazard ratio: 63.79; 95% confidence interval: 5.05-805.40; P = .001). This study did not verify the putative association between treatment failure and implementation of echocardiography in patients with uncomplicated S. aureus CRBSI. Given the low observed rates of adverse outcomes, routine echocardiography might not be obligatory and could be performed on an individual basis.

ACR Appropriateness Criteria® Infective Endocarditis

Infective endocarditis can involve a normal, abnormal, or prosthetic cardiac valve. The diagnosis is typically made clinically with persistently positive blood cultures, characteristic signs and symptoms, and echocardiographic evidence of valvular vegetations or valvular complications such as abscess, dehiscence, or new regurgitation. Imaging plays an important role in the initial diagnosis of infective endocarditis, identifying complications, prognostication, and informing the next steps in therapy. This document outlines the initial imaging appropriateness of a patient with suspected infective endocarditis and for additional imaging in a patient with known or suspected infective endocarditis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Injection Drug Use Endocarditis: An Inner-City Hospital Experience

Background

There has been a rise in the incidence of injection drug use and associated infective endocarditis.

Methods

The clinical outcomes of 39 patients admitted with injection drug use-associated infective endocarditis were collected with a mean follow-up of 14 months. The outcomes were compared for patients treated medically with those undergoing surgical intervention. Re sults: The mean age was 39 ± 11 years; 54% were female. Thirty-two patients (82%) had native and 7 (18%) prosthetic infective endocarditis. The tricuspid valve was affected in 17 patients (43%), the mitral in 10 (26%), the aortic in 4 (10%), and multiple valves in 8 (20%). Sixteen (41%) patients underwent surgery, and 23 (59%) were treated with medical therapy. The indications for surgery included heart failure, systemic emboli, recurrent infection, and vegetation size ≥10 mm. Patients undergoing surgery had a higher rate of paravalvular abscess (25% vs 0%, P = 0.02), valve perforation (37% vs 11%, P = 0.04), and mitral valve involvement (44% vs 13%, P = 0.06), whereas medically treated patients had higher tricuspid valve involvement (61% vs 19%, P = 0.02). During follow-up, 26% of medical and 31% of surgical cohort patients died (P = 0.7). Mortality was highest (54%) among those who continued medical management despite an indication for surgery. Univariate predictors of mortality were age (odds ratio [OR] 1.09, 95% confidence interval [CI]: 1.01-1.17; P = 0.02), heart failure (OR 6.9; 95% CI: 1.24-37.49; P = 0.02), septicemia (OR 4.40; 95% CI:0.99-19.54; P = 0.05), and shock (OR 10.8; 95% CI: 1.68-69.92; P = 0.01).

Conclusions

Despite contemporary therapy, patients with injection drug use-associated infective endocarditis remain at high risk of complications and poor clinical outcomes. These findings highlight the need for developing new care pathways and a team approach for effective management.

Infective endocarditis complicated by embolic events: Pathogenesis and predictors

BACKGROUND

Infective endocarditis (IE) continues to be associated with great challenges. Embolic events (EE) are frequent and life-threatening complications in IE patients. It remains challenging to predict and assess the embolic risk in individual patients with IE accurately.

HYPOTHESIS

Accurate prediction of embolization is critical in the early identification and treatment of risky and potentially embolic lesions in patients with IE.

METHODS

We searched the PubMed, Web of Science, and Google Scholar databases using a range of related search terms, and reviewed the literatures about the pathogenesis and embolic predictors of IE.

RESULTS

The development of IE and its complications is widely accepted as the result of complex interactions between microorganisms, valve endothelium, and host immune responses. The predictive value of echocardiographic characteristics is the most powerful for EE. In addition, both easily obtained blood biomarkers such as C-reactive protein, mean platelet volume, neutrophil-to-lymphocyte ratio, anti-β2-glycoprotein I antibodies, D-Dimer, troponin I, matrix metalloproteinases, and several microbiological or clinical characteristics might be promising as potential predictors of EE.

CONCLUSION

Our review provides a synthesis of current knowledge regarding the pathogenesis and predictors of embolism in IE along with a review of potentially emerging biomarkers.

Purulent pericarditis-induced intracardiac perforation and infective endocarditis due to Parvimonas micra: a case report

BACKGROUND

Purulent pericarditis, a rare disease with a high associated mortality rate in patients without adequate treatment, can cause serious complications, such as perforation of the surrounding tissue and organs. Parvimonas micra is a very rare cause of purulent pericarditis.

CASE SUMMARY

A 70-year-old male patient presented to our emergency room with chest pain of 10 days' duration. An electrocardiogram showed ST-segment elevation and PR-segment depression on multiple leads. A transthoracic echocardiogram showed normal left ventricular function and a large amount of pericardial effusion. Acute pericarditis was diagnosed, and anti-inflammatory drug therapy was initiated. Due to the lack of improvement in the symptoms, pericardiocentesis was performed on Day 8 and revealed about 800 cc of the bloody fluid. Parvimonas micra was detected in a culture of the pericardial effusion and blood. Although intravenous antibiotic therapy was initiated for purulent pericarditis, his fever persisted. Computed tomography of the chest performed on Day 14 showed an abscess cavity in the pericardial space around the right atrium (RA). Furthermore, transoesophageal echocardiography revealed vegetation in the RA. Emergency surgery confirmed the presence of vegetation and minor perforation of the RA with communication to the abscess cavity. After surgical therapy, the patient clinically improved and was discharged on Day 51.

DISCUSSION

In cases of acute pericarditis, purulent pericarditis should be considered if clinical improvement is not observed after initial treatment with anti-inflammatory drugs. Once the diagnosis of purulent pericarditis is made, aggressive source control is necessary for improved clinical outcomes.

Isolated Native Tricuspid Valve Endocarditis in a Nonintravenous Drug User

Infective endocarditis (IE) is a disease characterized by high morbidity and mortality. IE was first described in the mid-16th century. Right-sided infective endocarditis (RSIE) represents 5% to 10% of all IE episodes in adults. RSIE can be divided into three groups according to the underlying risk factors: intravenous drug users (IDUs), cardiac device carriers, and the “three noes” group (no left-sided IE, no IDUs, and no cardiac devices). Tricuspid valve endocarditis in nonintravenous drug users can occur in a variety of conditions including congenital heart disease, intracardiac devices, central venous catheters, and immunologically debilitated patients. Due to the rareness of isolated native nonrheumatic tricuspid valve endocarditis, here, we like to present an 18-year-old male from rural Ethiopia with the diagnosis of isolated native tricuspid valve endocarditis that was treated and cured.

A narrative review of echocardiography in infective endocarditis of the right heart

Infective endocarditis (IE) is characterized by bacterial or fungal masses that form in the cardiac chambers and valves, and in severe cases invade the endocardium or intra-cardiac vessels. Right-sided IE accounts for 5% to 10% of cases, with a low mortality cited at 6%. A history of intravenous drug abuse (IVDU) is present in 90% of isolated right-sided IE cases, with normal intra-cardiac anatomy prior to infection in approximately 80%. Nevertheless, up to 50% of patients require early surgical intervention which is associated with significant peri-operative morbidity. Echocardiography is the gold standard for diagnosis with a sensitivity of 80% for the transthoracic modality and 95% for transesophageal studies; it provides important clinical information regarding the severity of infection and development of secondary complications. This includes identification of active infective vegetations, healed IE, prosthetic valve IE, and abscess formation and rupture. Prompt clinical, microbiologic, and imaging assessment of patients with suspected left or right-sided IE is of paramount importance and is reflected in the modified Duke criteria, the well-validated algorithm for accurate and timely diagnosis of IE. Data suggests the criteria sensitivity may be decreased in right-sided IE only, and thus, care must be taken to perform skilled and detailed echocardiographic assessments of the right heart in suspected cases. Herein we provide a review of IE of the right heart, with a focus on pathophysiology and its echocardiographic presentation and characteristics.

Serratia marcescens Tricuspid Valve Vegetation and Successful Use of the AngioVac® System

Serratia marcescens bacteremia is common in patient populations with a history of intravenous drug use (IVDU), but it rarely causes infective endocarditis. We are reporting a 27-year-old female with a medical history significant for IVDU and hepatitis C virus infection who presented to the emergency department complaining of fever and shortness of breath. Computed tomography of the chest with intravenous (IV) contrast revealed extensive bilateral pulmonary infiltrates with multiple cavitary lesions. The patient was treated with IV vancomycin and piperacillin/tazobactam. Blood culture grows methicillin-sensitive Staphylococcus aureus (MSSA) and S. marcescens, both sensitive to cefepime/meropenem. Transesophageal echocardiogram revealed 3.4 x 2 cm tricuspid valve vegetation. Cardiothoracic surgery was consulted, who recommended transcatheter aspiration with the AngioVac® system (AngioDynamics Inc., Latham, NY). Post-procedure transesophageal echocardiogram revealed a significant reduction of vegetation size. Vegetation tissue culture grew MSSA and S. marcescens. The repeated blood culture revealed no growth, and the patient significantly improved clinically. She completed a six-week course of IV meropenem as an inpatient until she was discharged home.

Drug use associated tricuspid valve infective endocarditis in pregnancy

BACKGROUND AND AIM

We report a case of intravenous drug use associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-week gestation.

METHODS

Patient management required a multidisciplinary collaboration between cardiac surgery, obstetrics and gynecology, and neonatal critical care.

RESULTS

Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement 1 week later.

CONCLUSIONS

Both the patient and her infant were successfully managed through the perioperative period.

Right-Sided Infective Endocarditis 2020: Challenges and Updates in Diagnosis and Treatment

Compared with the extensive data on left-sided infective endocarditis (IE), there is much less published information on the features and management of right-sided IE. Right-sided IE accounts for 5% to 10% of all IE cases, and compared with left-sided IE, it is more often associated with intravenous drug use, intracardiac devices, and central venous catheters, all of which has become more prevalent over the past 20 years. In this manuscript on right-sided IE we provide an up-to-date overview on the epidemiology, etiology, microbiology, potential locations of infection in the right heart, diagnosis, imaging, common complications, management, and prognosis. We present updated information on the treatment of pacemaker and device infections, infected fibrin sheaths that appear to be an easily missed source of infection after central line as well as pacemaker removal. We review current data on the AngioVac percutaneous aspiration device, which can obviate the need for surgery in patients with infected pacemaker leads and fibrin sheaths. We also focused on advanced diagnostic modalities, such as positron emission tomography/computed tomography. All of these are supported by specific case examples with detailed echocardiographic imaging from our experience.

Bacterial co-infections and superinfections in COVID-19: a case report of right heart infective endocarditis and literature review

Coronavirus disease of 2019 (COVID-19) is a worldwide pandemic with significant morbidity and mortality. Patients with severe forms of the disease are usually managed in the Intensive Care Unit (ICU), where they can develop secondary infections particularly bacterial, favored by prolonged intubation and central venous catheterization (CVC), hence increasing the disease’s mortality. Infectious endocarditis (IE) represents a rare and severe cardiovascular complication in patients with CVC. We report the case of a patient admitted to the ICU for an acute respiratory distress syndrome (ARDS) due to COVID19. Her management included intubation and mechanical ventilation, CVC and treatment with Hydroxychloroquine and azithromycin, and echocardiography findings were unremarkable. On the 10th day of onset, the patient developed septic shock and both echocardiography and blood cultures were in favor of A positive diagnosis of tricuspid valve infective endocarditis, accordingly to the modified Duke criteria. Specific treatment was started with a good clinical evolution. Our case outlines the difficulty of management of bacterial co-infections and superinfections in COVID-19 ICU patients, and particularly rare infections such as right-heart IE, which usually require a multidisciplinary approach and coordination between intensivits, cardiologists and infectiologists.

Widespread septic embolization in injection drug use mitro-aortic infective endocarditis as a remote cause of death

Injection drug use-related infective endocarditis (IDU-IE) assumes peculiar epidemiological, pathogenetic, and prognostic characteristics that allow to consider it a distinct nosological entity, as well as a current problem of considerable social weight. Incidence is reasonably underestimated because diagnosis is often accidental in postmortem examination when drug-related death is suspected. In many cases, postmortem toxicological examinations are negative for acute drug abuse, and findings of infective endocarditis became relevant in the explanation of the mechanism of death. Extracardiac involvement of infective endocarditis is rarely reported as fatal. Fragmentation and embolization of bacterial vegetations can be associated with parenchymal infarcts, systemic spread of the infectious process by formation of an abscess. A case of septic shock as a consequence of the constant bacteremia determined by the continuous proliferation and release of bacteria into the circulation is presented in an injection drug user with left-sided endocarditis and widespread septic embolization. Authors reviewed forensic and medical literature and promote epidemiological value of medical and forensic autopsy. Extracardiac involvement of infective endocarditis may represent a remote and alternative cause of death in injection drug users, and an early diagnosis can be relevant for prognosis. Postmortem examination still represents a valuable opportunity of learning for clinicians and improving diagnostic accuracy with injection drug users. A call for changing of attitudes and practice toward autopsy is finally demanded.

Systemic septic emboli in tricuspid endocarditis due to an atrial communication with a right-to-left shunt

We present the case of a patient admitted to hospital in septic shock. He had a history of tricuspid valve infective endocarditis (IE) 6 months prior and regularly injected intravenous drugs. A bedside echo on arrival confirmed vegetations on his tricuspid valve, torrential tricuspid regurgitation and signs of significantly raised right-sided pressures. The admission chest radiograph showed consolidative changes in the lungs, suggestive of septic pulmonary emboli. He was commenced on antibiotics and treated in the high-dependency unit. He subsequently developed an acutely ischaemic right foot and nasal tip. Suspicions were raised of a paradoxical septic embolus through a right-to-left shunt, subsequently confirmed on bubble echo which showed passage of agitated saline between the atria. This was not apparent clinically or on echocardiogram during his previous episode of tricuspid valve IE, raising the possibility of the development of an acquired inter-atrial communication since his previous episode.

Characteristics and outcomes of patients with right-sided endocarditis undergoing cardiac surgery

Background

There has been an increasing incidence of right-sided infective endocarditis (RSIE) due to the global rise of intravenous drug use (IVDU) and an increasing number of implantable cardiac electronic devices and central venous catheters. Our aim was to investigate differences in the clinical presentation, microbiological findings and prognosis of patients undergoing surgery for RSIE compared to left-sided infective endocarditis (LSIE).

Methods

Relevant clinical data of all 432 consecutive patients undergoing valve surgery for infective endocarditis (IE) at our institution between January 2009 and December 2018 were retrospectively analyzed. Acquired data included patients' demographic and preoperative comorbidities, manifestation of IE according to the recently modified Duke Criteria, perioperative data and relevant clinical outcomes.

Results

A total of 403 patients (93.3%) underwent surgery for LSIE and twenty-nine patients (6.7%) for RSIE. Eleven patients with RSIE (37.9%) showed a concomitant left-sided infection. Compared to LSIE, RSIE patients were significantly younger [47.5 (40.4-69.3) vs. 65.1 (53.7-74.6); P=0.008] and presented with less comorbidities such as hypertension (41.4% vs. 65.3%; P=0.010) and coronary artery disease (6.9% vs. 29.0%; P=0.010). Rates of IVDU (34.5% vs. 4.5%; P<0.001), human immunodeficiency virus (HIV) (10.3% vs. 1.7%; P=0.023) and hepatitis C virus (HCV) infection (24.1% vs. 5.2%; P=0.001) were greater in RSIE. The proportion of Staphylococcus aureus IE was significantly higher in RSIE compared to LSIE (37.9% vs. 21.1%; P=0.035). 30-day mortality was 6.9% after surgery for RSIE compared to 14.6% after operation for LSIE (P=0.372).

Conclusions

Patients undergoing surgery for RSIE compared to LSIE presented with a higher rate of pulmonary septic emboli, more Staphylococcus aureus infections and larger vegetations. Larger multicenter prospective trials are needed to provide more reliable data on the clinical profile of these patients, in order to determine optimal surgical management.

A rare case of right-sided infective endocarditis caused by group B Streptococcus complicated with septic knee arthritis and subcutaneous abscess in the lower extremity

Background

Several reports have assessed group B Streptococcus (GBS) infections in non‐pregnant cohorts, especially in immunocompromised hosts and patients with severe disease, including diabetes mellitus.

Case presentation

We report a rare case of large GBS‐associated tricuspid valve infective endocarditis (IE) complicated with septic knee arthritis and s.c. abscess formation in the lower extremity of a non‐i.v. drug user. After confirming the absence of vegetation on transthoracic echocardiography (TTE) at admission, the lower extremity was irrigated, and antibiotic therapy was initiated. One week later, the causes of persistent fever were reinvestigated. The TTE detected a large mass around the tricuspid valve. The cultured GBS was penicillin sensitive. The vegetation completely disappeared without surgery within 4 weeks.

Conclusion

When patients with untreated diabetes mellitus have persistent fever and s.c. abscess or septic arthritis, IE is a possible differential diagnosis. Repetitive evaluation by TTE is warranted to avoid this fatal complication.

Pulmonic valve infective endocarditis from staph lugdunensis

Pulmonic valve endocarditis is an extremely rare entity. Only 1.1% of all cases of all infective endocarditis affect the pulmonic valve. Furthermore, it is even more uncommon for such a disease process to occur in a young and healthy individual without risk factors. It takes a unique case of circumstances to have pulmonic valve infective endocarditis to occur. Staph lugdunensis is one uncommonly isolated organism that has the ability to cause infective endocarditis in various atypical manifestations. Here we describe a case of a 20-year-old male who did not possess any of the common risk factors of infective endocarditis, who developed isolated pulmonic valve endocarditis caused by Staphylococcus lugdunensis (S. lugdunensis). Based upon our literature review, only 1 other case of S. lugdunensis endocarditis affective the pulmonic valve has been reported.

Endocarditis in the setting of IDU: multidisciplinary management

PURPOSE OF REVIEW

The purpose of this article is to provide a brief overview of the medical and surgical management of infective endocarditis secondary to IDU, with a focus on the underlying substance use disorder.

RECENT FINDINGS

Patients with infective endocarditis secondary to IDU are often young with unique comorbidities including mental illness, chronic hepatitis C, HIV infection, which are often compounded by limited social and familial supports. The focus of management has been treatment of endocarditis using IV antibiotics alongside surgery. Surgical outcomes compare favorably with those of infective endocarditis in the general population but long-term outcomes of IDUs are significantly worse. This is primarily due to the high rate of recidivism of drug use and the risk of prosthetic valve infective endocarditis. Contemporary management of addiction utilizes an integrative approach, combining both pharmacologic and nonpharmacologic strategies while remaining patient-centered. Given the complexity of care required, we advocate for a multidisciplinary team-based approach including psychiatry, infectious disease, cardiology, cardiac surgery and social services.

SUMMARY

Infective endocarditis secondary to IDU remains a medical and surgical challenge with dismal outcomes. Here we offer practical suggestions on the multidisciplinary management of this challenging and high-risk patient cohort.

Rare Simultaneous Left and Right-Sided Native Valve Infective Endocarditis Caused by Rare Bacterium

Simultaneous left and right-sided native valve infective endocarditis (IE) is rare. Staphylococcus aureus was the predominant organism for bilateral IE. Shunt diseases are common risk factors of both-sided IE. Streptococcus anginosus (S. anginosus) is usually associated with pyogenic infections, but rarely a cause of IE. Here we present an extremely rare case of simultaneous left and right-sided native valve IE affecting the mitral and tricuspid valves caused by S. anginosus in an adult patient that has not been reported in the literature previously, particularly without the most frequent predisposing factors of IE. A 66-year-old man was admitted due to generalized fatigue, chills, malaise, and intermittent fevers for 1 year. A grade III-IV/VI systolic murmur at the mitral area and a III/VI systolic murmur at the tricuspid area were noted on physical examination. Laboratory evaluation revealed an elevated erythrocyte sedimentation rate and C-reactive protein level, and high fasting blood glucose. Blood culture was positive for S. anginosus. Echocardiography revealed vegetations in both sides of the heart: a large mitral valve vegetation with severe mitral regurgitation, as well as another vegetation on the tricuspid valve with moderate regurgitation. The case highlights a rare pathogen of both-sided IE, a rare presentation of S. anginosus infection, and several points worthy of note in echocardiography of IE.