Management of infective endocarditis: challenges and perspectives

Characteristics associated with occurrence of stroke in patients with infective endocarditis - a retrospective cohort study

BACKGROUND

Stroke is a severe complication of infective endocarditis (IE), associated with high rates of mortality. Data on how IE patients with and without stroke differ may help to improve understanding contributing mechanisms.

METHODS

All patients treated for IE between 2019 and 2021 with and without associated stroke were identified from the medical records of three academic tertiary care hospitals in Germany, all part of Charité - Universitätsmedizin Berlin, Germany. Multivariable logistic regression analyses were performed to identify variables associated with the occurrence of stroke.

RESULTS

The study population consisted of 353 patients diagnosed with IE. Concomitant stroke occurred in 96/353 (27.2%) patients. Acute stroke was independently associated with co-occurring extracerebral arterial embolism [adjusted Odds ratio (aOR = 2.52; 95% confidence interval (CI) 1.35-4.71)], acute liver failure (aOR = 2.62; 95% CI 1.06-6.50), dental focus of infection (aOR = 3.14; 95% CI 1.21-8.12) and left-sided IE (aOR = 28.26; 95% CI 3.59-222.19). Stroke was found less often in IE patients with congenital heart disease (aOR = 0.20; 95% CI 0.04-0.99) and atypical pathogens isolated from blood culture (aOR = 0.31; 95% CI 0.14-0.72).

CONCLUSIONS

Stroke is more likely to occur in individuals with systemic complications affecting other organs, too. Special attention should be addressed to dental status. The low incidence of stroke in patients with congenital heart disease may reflect awareness and prophylactic measures.

The Predictive Value of Sepsis Scores for In-Hospital Mortality in Patients with Left-Sided Infective Endocarditis

BACKGROUND

As infective endocarditis has particular characteristics compared to other infectious diseases, it is not clear if sepsis scores are reported with good accuracy in these patients. The aim of this study is to evaluate the accuracy of the qSOFA and SOFA scores to predict mortality in patients with infective endocarditis.

METHODS

Between January 2010 and June 2019, 867 patients with suspected left-sided endocarditis were evaluated; 517 were included with left-sided infective endocarditis defined as "possible" or "definite" endocarditis, according to the Modified Duke Criteria. ROC curves were constructed to assess the accuracy of qSOFA and SOFA sepsis scores for the prediction of in-hospital mortality.

RESULTS

The median age was 57 years, 65% were male, 435 (84%) had pre-existing heart valve disease, and the overall mortality was 28%. The most frequent etiologies were Streptococcus spp. (36%), Enterococcus spp. (10%), and Staphylococcus aureus (9%). The sepsis scores from the ROC curves used to predict in-hospital mortality were qSOFA 0.601 (CI95% 0.522-0.681) and SOFA score 0.679 (CI95% 0.602-0.756). A sub-group analysis in patients with and without pre-existing valve disease for SOFA ≥ 2 showed ROC curves of 0.627 (CI95% 0.563-0.690) and 0.775 (CI95% 0.594-0.956), respectively.

CONCLUSIONS

qSOFA and SOFA scores were associated with increased in-hospital mortality in patients with infective endocarditis. However, as accuracy was relatively lower compared to other sites of bacterial infections, we believe that this score may have lower accuracy when predicting the prognosis of patients with IE, because, in this disease, the patient's death may be more frequently linked to valvular and cardiac dysfunction, as well as embolic events, and less frequently directly associated with sepsis.

Impact of heart failure and preoperative platelet count on the postoperative short-term outcome in infective endocarditis patients

BACKGROUND

Heart failure (HF) and platelet count are often considered risk factors for mortality in patients with infective endocarditis (IE); however, their effects on various complications have not been elucidated.

HYPOTHESIS

We speculated that HF and platelet count have significant impact on the short-term outcomes of IE.

METHODS

This single-center retrospective study analyzed data from 320 IE patients who underwent surgery. A multivariate Cox proportional hazards model was used to identify the risk factors for adverse outcomes. The effect of the platelet count on the prognosis of patients with HF was determined by subgroup analysis and Kaplan-Meier analysis.

RESULTS

The study population was divided into the HF group (n = 102) and the non-HF group (n = 218). The median age of the total population was 44.5 years (31-56 years), of which 227 (70.94%) patients were male. The incidence rates of 1-year all-cause mortality, cardiac outcomes, and composite outcomes were respectively almost sixfold, fourfold, and threefold higher in the HF group than in the non-HF group (all p < 0.001). In multivariate Cox regression analysis, HF was an independent risk factor for 1-year all-cause mortality, cardiac outcomes, cerebral outcomes, and composite outcomes. The Kaplan-Meier survival curves revealed that the patients with both HF and thrombocytopenia demonstrated the worst composite outcomes than the patients of the other groups (log-rank p < 0.001). In the HF group, the platelet count was significantly associated with mortality and composite outcomes.

CONCLUSIONS

HF and preoperative platelet count are significantly associated with 1-year all-cause mortality and adverse outcomes postoperatively in IE patients. Patients with HF and thrombocytopenia have the worst short-term prognosis.

A Nationwide Study on Mitral Valve Repair vs Replacement for Active Endocarditis

BACKGROUND

Real-world evidence supporting the reproducibility and superiority of valve repair over replacement in active mitral valve infective endocarditis is lacking.

METHODS

Data from a prospective nationwide database, including all cardiac surgical procedures in The Netherlands, were used. Adult patients undergoing primary mitral valve intervention who had a diagnosis of active infective endocarditis and who underwent surgery between 2013 and 2020 were included. Survival analysis was performed for the whole follow-up period as well as after applying the landmark of 90 days.

RESULTS

Of 715 patients who met the inclusion criteria, 294 (41.1%) underwent valve repair. Mitral valve repair rates decreased slightly over the course of the study. The early mortality rate was 13.0%, and a trend of steadily declining early mortality rates over the course of the study, despite a steady increase in patient complexity, was observed. On risk-adjusted analysis, mitral valve replacement demonstrated inferior results when compared with valve repair (adjusted hazard ratio, 2.216; 95% CI, 1.425-3.448; P < .001), even after a landmark analysis was performed (adjusted hazard ratio 2.489; 95% CI, 1.124-5.516; P = .025). These results were confirmed by a propensity score-adjusted analysis (adjusted hazard ratio 2.251; 95% CI, 1.029-4.21; P = .042).

CONCLUSIONS

Contemporary trends in mitral valve surgery for active infective endocarditis suggest growing patient complexity but slightly declining early mortality rates. A trend of decreasing mitral valve repair rates was seen. The results of this study suggest improved late outcomes of valve repair compared with valve replacement.

Clinical evaluation of Sepsis-1 and Sepsis-3 in infective endocarditis

BACKGROUND

Sepsis is associated with poor survival outcomes in patients with infective endocarditis (IE). However, the prognostic value of the Sepsis-1 and Sepsis-3 criteria of sepsis for IE patients is unclear.

METHODS

A total of 1354 patients with IE was enrolled and classified into the sepsis and non-sepsis groups according to the Sepsis-1 and Sepsis-3. Multivariate regression analysis was performed to test the predictive performances of the Sepsis-1 and Sepsis-3 in assessing the risk of mortality in patients with IE.

RESULTS

Sepsis was diagnosed in 347 (25.6%) patients according to the Sepsis-1 and 496 (36.6%) patients with the Sepsis-3. The in-hospital mortality rate was 11.5% in the Sepsis-1 group and 14.3% in the Sepsis-3 group. Kaplan-Meier survival curve analysis showed that both Sepsis-1 (Log-rank = 17.2, p < 0.001) and Sepsis-3 (Log-rank = 94.3, p < 0.001) were significantly associated with 6-month mortality. Multivariate regression analysis demonstrated that the Sepsis-3 was independently associated with the in-hospital mortality (odds ratio = 2.89, 95% CI 1.68-4.97, p < 0.001) and the 6-month mortality (hazard ratio = 3.24, 95% CI 2.08-5.04, p < 0.001).

CONCLUSIONS

Sepsis-3 shows better predictive performance than Sepsis-1 criteria in assessing the risk of mortality in patients with IE.

Predictors of embolism and death in left-sided infective endocarditis: the European Society of Cardiology EURObservational Research Programme European Infective Endocarditis registry

BACKGROUND AND AIMS

Even though vegetation size in infective endocarditis (IE) has been associated with embolic events (EEs) and mortality risk, it is unclear whether vegetation size associated with these potential outcomes is different in left-sided IE (LSIE). This study aimed to seek assessing the vegetation cut-off size as predictor of EE or 30-day mortality for LSIE and to determine risk predictors of these outcomes.

METHODS

The European Society of Cardiology EURObservational Research Programme European Infective Endocarditis is a prospective, multicentre registry including patients with definite or possible IE throughout 2016-18. Cox multivariable logistic regression analysis was performed to assess variables associated with EE or 30-day mortality.

RESULTS

There were 2171 patients with LSIE (women 31.5%). Among these affected patients, 459 (21.1%) had a new EE or died in 30 days. The cut-off value of vegetation size for predicting EEs or 30-day mortality was >10 mm [hazard ratio (HR) 1.38, 95% confidence interval (CI) 1.13-1.69, P = .0015]. Other adjusted predictors of risk of EE or death were as follows: EE on admission (HR 1.89, 95% CI 1.54-2.33, P < .0001), history of heart failure (HR 1.53, 95% CI 1.21-1.93, P = .0004), creatinine >2 mg/dL (HR 1.59, 95% CI 1.25-2.03, P = .0002), Staphylococcus aureus (HR 1.36, 95% CI 1.08-1.70, P = .008), congestive heart failure (HR 1.40, 95% CI 1.12-1.75, P = .003), presence of haemorrhagic stroke (HR 4.57, 95% CI 3.08-6.79, P < .0001), alcohol abuse (HR 1.45, 95% CI 1.04-2.03, P = .03), presence of cardiogenic shock (HR 2.07, 95% CI 1.29-3.34, P = .003), and not performing left surgery (HR 1.30 95% CI 1.05-1.61, P = .016) (C-statistic = .68).

CONCLUSIONS

Prognosis after LSIE is determined by multiple factors, including vegetation size.

The Deadly Contaminant: A Case of Staphylococcus lugdunensis Endocarditis

The incidence of infective endocarditis (IE) has been on the rise since it was first reported a century ago, and the associated mortality remains unchanged despite advances in medical and surgical management. To diagnose IE, the modified Duke criteria are used, which rely on isolating the causative organism. However, this can be challenging if the micro-organism is considered a contaminant. Staphylococcus lugdunensis (SL) is one such organism. In this case, an elderly female presented with intermittent chest pain, palpitation, and diaphoresis, for which she underwent left heart catheterization. Her hospital course was complicated by persistent fever and night sweats, leading to blood cultures isolating methicillin sensitivity. It was initially reported as a contaminant. However, an extensive workup was unremarkable, and a transthoracic echocardiogram was done, which revealed tricuspid vegetations with moderate regurgitation. The patient was treated with cefazolin, repeat cardiac imaging at the end of treatment revealed no vegetation, and the patient remained asymptomatic. Despite being associated with fulminant IE with higher mortality than Staphylococcus aureus (S. aureus), which requires surgical management in most cases, SL is still often reported as a contaminant. Isolation of SL should warrant further investigation beyond mere contaminants, and prompt treatment should be initiated in the appropriate clinical scenario to avoid poor outcomes.

The Bacterial Oral Microbiome in Children with Congenital Heart Disease: An Extensive Review

Children with congenital heart disease have poorer oral health compared with healthy children. Oral diseases, such as dental caries and gingivitis, are associated with the oral microbiome. The objective of this review was to find evidence of differences in the bacterial colonization of the oral cavity of children with congenital heart disease (CHD) versus healthy children. A literature review was conducted according to predetermined criteria, including the need for controlled clinical trials. Half of the 14 studies that met the inclusion criteria reported significant differences in bacterial colonization in children with congenital heart disease. A variety of influencing factors were discussed. There is some evidence for alterations in the oral microflora as a result of physiopathological and treatment-related factors in children with CHD, but additional research is required to validate these findings.

Case report: Diagnostic and therapeutic challenges of fungal endocarditis by Trichosporon asahii in a child with congenital heart defects

Background

patients with congenital cardiopathies are the main group at risk for infective endocarditis (IE) in the pediatric population. Fungal etiology is responsible for 2%-4% of all IEs, and the Trichosporon genus is an increasingly prevalent cause of infections in human beings.

Case presentation

We describe a 9-year-old male with multiple surgical procedures to correct congenital cardiopathy defects, including insertion of RV-PA conduit, who was admitted due to suspicion of pneumonia and needed a surgical approach after being diagnosed with a mycotic pseudoaneurysm in the right ventricle's outflow tract, with dilation of the RV-PA conduit. The conduit was removed and antifungal treatment was started with Voriconazole after the agent was identified (T. asahii), with satisfactory therapeutic response. Approximately 4 years later, the patient was readmitted, presenting with intermittent fever, associated with nocturnal diaphoresis, dry cough, anxiety and chest pain. Vegetations consistent with T. asahii were evidenced in the RV-PA conduit, and a surgical approach was once again necessary.

Discussion

diagnostic methods and treatment of T. asahii endocarditis aren't yet standardized, and recurrent surgical approaches are needed due to the inefficacy of antifungal treatment.

Genome Analysis of ST1 Bartonella henselae, a Zoonotic Pathogen Causing Endocarditis in an Elderly Patient in China

Infective endocarditis (IE) is a rare disease but with high associated mortality. Currently, the mainstays of diagnosis are still echocardiography and blood cultures. Here, we reported a case of infective endocarditis with negative blood cultures, and blood and aortic valve tissue metagenomic next-generation sequencing (mNGS) results suggested Bartonella henselae. In addition, we obtained the whole genomic sequence of B. henselae ZJBH strain. To our knowledge, this is the first report of B. henselae genomic analysis isolated from clinic in China. Furthermore, we described the whole genome sequencing (WGS) data incorporating all B. henselae from diverse sources worldwide and shed light on underlying risk of B. henselae transmitted between cats and humans.

16S rRNA Gene PCR/Sequencing of Heart Valves for Diagnosis of Infective Endocarditis in Routine Clinical Practice

Sequencing is increasingly used for infective endocarditis (IE) diagnosis. Here, the performance of 16S rRNA gene PCR/sequencing of heart valves utilized in routine clinical practice was compared with conventional IE diagnostics. Subjects whose heart valves were sent to the clinical microbiology laboratory for 16S rRNA gene PCR/sequencing from August 2020 through February 2022 were studied. A PCR assay targeting V1 to V3 regions of the 16S rRNA gene was performed, followed by Sanger and/or next-generation sequencing (NGS) (using an Illumina MiSeq), or reported as negative, depending on an algorithm that included the PCR cycle threshold value. Fifty-four subjects, including 40 with IE, three with cured IE, and 11 with noninfective valvular disease, were studied. Thirty-one positive results, 11 from NGS and 20 from Sanger sequencing, were generated from analysis of 16S rRNA gene sequence(s). Positivity rates of blood cultures and 16S rRNA gene PCR/sequencing of valves were 55% and 75%, respectively (P = 0.06). In those with prior antibiotic exposure, positivity rates of blood cultures and 16S rRNA gene PCR/sequencing of valves were 11% and 76%, respectively (P < 0.001). Overall, 61% of blood culture-negative IE subjects had positive valve 16S rRNA gene PCR/sequencing results. 16S rRNA gene-based PCR/sequencing of heart valves is a useful diagnostic tool for pathogen identification in patients with blood culture-negative IE undergoing valve surgery in routine clinical practice.

Contemporary Clinical Profile of Left-Sided Native Valve Infective Endocarditis: Influence of the Causative Microorganism

Studies focused on the clinical profile of native valve endocarditis are scarce and outdated. In addition, none of them analyzed differences depending on the causative microorganism. Our objectives are to describe the clinical profile at admission of patients with left-sided native valve infective endocarditis in a contemporary wide series of patients and to compare them among the most frequent etiologies. To do so, we conducted a prospective, observational cohort study including 569 patients with native left-sided endocarditis enrolled from 2006 to 2019. We describe the modes of presentation and the symptoms and signs at admission of these patients and compare them among the five more frequent microbiological etiologies. Coagulase-negative Staphylococci and Enterococci endocarditis patients were the oldest (71 ± 11 years), and episodes caused by Streptococci viridans were less frequently nosocomial (4%). The neurologic, cutaneous or renal modes of presentation were more typical in Staphylococcus aureus endocarditis (28%, p = 0.002), the wasting syndrome of Streptococcus viridans (49%, p < 0.001), and the cardiac in Coagulase-negative Staphylococci, Enterococci and unidentified microorganism endocarditis (45%, 49% and 56%, p < 0.001). The clinical signs agreed with the mode of presentation. In conclusion, the modes of presentation and the clinical picture at admission were tightly associated with the causative microorganism in patients with left-sided native valve endocarditis.

Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis.

Prognostic implications of ultra-short heart rate variability indices in hospitalized patients with infective endocarditis

BACKGROUND

Infective endocarditis (IE) is a disease that poses a serious health risk. It is important to identify high-risk patients early in the course of their treatment. In the current study, we evaluated the prognostic value of ultra-short heart-rate variability (HRV), an index of vagal nerve activity, in IE.

METHODS

Retrospective analysis was performed on adult patients admitted to a tertiary hospital due to IE. A logistic regression (LR) was used to determine whether clinical, laboratory, and HRV parameters were predictive of specific clinical features (valve type, staphylococcal infection) or severe short-term complications (cardiac, metastatic infection, and death). The accuracy of the model was evaluated through the measurement of the area under the curve (AUC) of the receiver operating characteristic curve (ROC). An analysis of survival was conducted using Cox regression. A number of HRV indices were calculated, including the standard deviation of normal heart-beat intervals (SDNN) and the root mean square of successive differences (RMSSD).

RESULTS

75 patients, aged 60.3(±18.6) years old, were examined. When compared with published age- and gender-adjusted HRV norms, SDNN and RMSSD were found to be relatively low in our cohort (75%-76% lower than the median; 33%-41% lower than the 2nd percentile). 26(34.6%) patients developed a metastatic infection, with RMSSD<7.03ms (adjusted odds ratio (aOR) 9.340, p = 0.002), incorporated in a multivariate LR model (AUC 0.833). Furthermore, 27(36.0%) patients were diagnosed with Staphylococcus IE, with SDNN<4.92ms (aOR 5.235, p = 0.004), a major component of the multivariate LR model (AUC 0.741). Multivariate Cox regression survival model, included RMSSD (HR 1.008, p = 0.012).

CONCLUSION

SDNN, and particularly RMSSD, derived from ultra-short ECG recordings, may provide prognostic information about patients presenting with IE.

Percutaneous debulking of tricuspid vegetations due to infectious endocarditis in pregnancy: a case report

Infective endocarditis is a rare but serious disease with increasing prevalence in women of childbearing age because of the opioid epidemic. Therefore, it is an increasingly frequent pregnancy complication. The gold standard of treatment is intravenous antibiotics with surgery reserved for refractory cases. However, pregnancy complicates decisions about the risk and timing of surgery. AngioVac represents a percutaneous alternative to surgical intervention. Here, we present a case of a 22-year-old G2P1001 woman with a history of intravenous drug use and infective endocarditis who continued to show signs and symptoms of septic pulmonary emboli despite management with intravenous antibiotics. The patient was deemed not to be a surgical candidate while pregnant and had an AngioVac procedure at 30 2/7 weeks of gestation with the removal of tricuspid vegetations. The patient was delivered via cesarean delivery at 32 5/7 weeks of gestation because of a nonreassuring fetal heart tracing. The patient's tricuspid valve was replaced on postpartum day 16. This case demonstrates that AngioVac can be safely used in the third trimester of pregnancy and may be considered in consultation with a multidisciplinary team for the management of infective endocarditis refractory to antibiotic treatment as an interim measure until surgery can be safely performed.

Outcomes of Cardiac Arrest with Valve Surgery Among Infective Endocarditis Patients: A United States National Cohort Study

OBJECTIVE

Cardiac arrest can complicate infective endocarditis (IE) and is associated with significant in-hospital complications and mortality rates. We report the characteristics, outcomes, and readmission rates for IE patients with cardiac arrest in the United States.

METHODS

We surveyed the Nationwide Readmission Database (NRD), a database designed to support national level readmission analyses, for patients admitted with IE and who had cardiac arrest during index admission between 2016 and 2019. Baseline demographics, comorbidities, surgical procedures, and outcomes were identified using their respective International Classification of Diseases (ICD) codes.

RESULTS

There were 663 index admissions (mean age 55.87 ± 17.21 years;34.2 % females) for IE with cardiac arrest in the study period, with an overall mortality rate of 55.3 %. Of these, 270 (40.7 %) had surgical procedures performed during the hospitalization encounter. In patients who had a surgical procedure, 72 (26.8 %) patients had in-hospital mortality while 293 (74.9 %) patients without surgical procedures had in-hospital mortality (p < 0.001). After coarsened matching for baseline characteristics, surgical valve procedures were less likely to be associated with mortality (OR = 0.09, 95%CI 0.04-0.24; p < 0.001). Among the 295 alive discharges associated with cardiac arrest, 76 (38.57 %) were readmitted within 30-days, with a mortality rate of 22 % noted for readmissions.

CONCLUSION

Among IE patients who had cardiac arrest, surgical procedures subgroup had low mortality despite having higher complication rates. However, due to chances of bias more randomized trials are needed evaluate the hypothesis.

A Case of Infective Endocarditis Treated With Homeopathy Medicine

Infective endocarditis is a deadly disease, associated with high mortality and morbidity. We present a case of a 14-year-old boy with antibiotic-resistant infective endocarditis who was treated with classical homeopathy. The case is analyzed according to the general reactivity of the organism and the Levels of Health theory.

Radionuclide Imaging of Infective Endocarditis

Infective endocarditis (IE) is associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management. Due to difficulties in the diagnosis, a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data is used. Imaging, including echocardiography, molecular imaging techniques, and coronary CT angiography (CTA) is central to detect infections involving heart valves and implanted cardiovascular devices, also allowing for early detection of septic emboli and metastatic. This article describes the main clinical application of white blood cell SPECT/CT and [¹⁸F]FDG-PET/CT and CTA in IE and infections associated with cardiovascular implantable electronic devices.

Infective Endocarditis Surgery. Insights from 328 Patients Operated in a University Tertiary Hospital

BACKGROUND

Infectious endocarditis (IE) refers to infection of the endocardial surface of the heart and usually occurs in native or prosthetic valves.

OBJECTIVE

This study aimed to raise IE data reflecting the surgical therapy in a University Hospital in the interior of the State of Sao Paulo-Brazil.

METHOD

Retrospective and observational approach of 328 patients with IE who underwent surgery between 1982 and 2020.

RESULTS

The main data (n=121/37%), congestive heart failure (n=114/35%), valve disease (n=92/28%), diabetes mellitus (n=85/26%), chronic kidney disease (n=59/18%), and rheumatic fever (49/15%). Renal failure is one of the main and most relevant pre-surgical risk factors for a poor prognosis.

CONCLUSION

For a better clinical and surgical outcome, an early syndromic and etiological diagnosis of IE is necessary, especially in patients with multiple comorbidities.

The Epidemiology of Infective Endocarditis in New South Wales, Australia: A Retrospective Cross-Sectional Study From 2001 to 2020

OBJECTIVES

This study aimed to investigate the demographic differences amongst patients diagnosed with infective endocarditis (IE), predictors of adverse events, and the association between clinical decision-making and adverse health outcomes amongst patients with IE.

DESIGN

A retrospective cross-sectional study was conducted using the New South Wales (NSW) Admitted Patient Data Collection (APDC) from the Centre for Health Record Linkage (CHeReL).

PARTICIPANTS

All patients (N=18,044) from 2001 to 2020 in New South Wales who received a diagnosis of IE using ICD-10-AM diagnostic code 133.0 were included.

METHODS

Categorical variables were compared using the chi-square test or Fisher's exact test, while the t-test was used for continuous variables. The association between clinical decision-making and adverse health outcomes amongst patients with IE were examined via generalised linear mixed models.

RESULTS

Sex, age, birthplace and referral impacted clinical decision-making, in-hospital death and severity of the disease. Women experienced a higher risk of death and fewer escalations of care. Admission and mortality increased with age, with those aged 60 and above responsible for 60.8% of hospitalisations. Despite octogenarians making up one-fifth of admissions and having the worst mortality rate (15.1%), they experienced only one in 10 intensive care (ICU) admissions. Overseas-born patients had fewer escalations of care and experienced less severe disease if referred by a medical practitioner. One out of 10 admissions that resulted in a hospital death were given non-emergency status, and one in two ICU patients died in hospital.

CONCLUSIONS

Sex, age, place of birth, and clinical decision-making were important predictors of severe disease and death in hospital, lending weight that health care clinical decisions may adversely impact health outcomes for populations of interest.

Application of metagenomic next-generation sequencing in patients with infective endocarditis

Objectives

Metagenomic next-generation sequencing (mNGS) technology is helpful for the early diagnosis of infective endocarditis, especially culture-negative infective endocarditis, which may guide clinical treatment. The purpose of this study was to compare the presence of culture-negative infective endocarditis pathogens versus culture-positive ones, and whether mNGS test results could influence treatment regimens for patients with routine culture-negative infective endocarditis.

Methods

The present study enrolled patients diagnosed with infective endocarditis and tested for mNGS in the First Affiliated Hospital of Zhengzhou University from February 2019 to February 2022 continuously. According to the culture results, patients were divided into culture-negative group (Group CN, n=18) and culture-positive group (Group CP, n=32). The baseline characteristics, clinical data, pathogens, 30 day mortality and treatment regimen of 50 patients with infective endocarditis were recorded and analyzed.

Results

Except for higher levels of PCT in the Group CN [0.33 (0.16-2.74) ng/ml vs. 0.23 (0.12-0.49) ng/ml, P=0.042], there were no significant differences in the basic clinical data and laboratory examinations between the two groups (all P>0.05). The aortic valve and mitral valve were the most involved valves in patients with infective endocarditis (aortic valve involved: Group CN 10, Group CP 16; mitral valve involved: Group CN 8, Group CP 21; P>0.05) while 9 patients had multiple valves involved (Group CN 2, Group CP 7; P>0.05). The detection rate of non-streptococci infections in the Group CN was significantly higher than that in the Group CP (9/18 vs. 3/32, P=0.004). There was no significant difference in patients with heart failure hospitalization and all-cause death at 30 days after discharge (3 in Group CN vs. 4 in Group CP, P>0.05). It is worth noting that 10 patients with culture-negative infective endocarditis had their antibiotic regimen optimized after the blood mNGS.

Conclusions

Culture-negative infective endocarditis should be tested for mNGS for early diagnosis and to guide clinical antibiotic regimen.

Can transthoracic echocardiography be used to a greater extent in the diagnostics of infective endocarditis to avoid unnecessary transoesophageal examinations without jeopardising accuracy?

BACKGROUND

Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is sometimes necessary because of its higher sensitivity for IE. Yet, TOE may imply an increased risk of complications. This project aims to evaluate whether TTE can be used to a greater extent in the diagnostics of IE to avoid unnecessary TOE examinations without jeopardizing diagnostic accuracy.

METHODS

Data from all TOE examinations performed on patients hospitalized with clinical suspicion of IE between 2019-05-01 and 2020-04-30 at a university hospital in Stockholm, Sweden, were obtained and analysed. Variables included for analysis were age, sex, blood culture results, aetiology, results from TOE, number of TOEs during the inclusion period, results from positron emission tomography/computed tomography (PET/CT), new regurgitation, cardiac murmur, previous IE, prosthetic valve, predisposing factors, i.e. cardiac comorbidities, injection drug use, fever, vascular phenomena, and immunological phenomena. To assess associations between predisposing factors or aetiology of IE and TOE findings, chi square tests and logistic regression models were used. For continuous variables, linear regression was used for comparisons of means and quantile regression was used for comparisons of medians. P < 0.05 was considered significant.

RESULTS

In total 195 TOE examinations (Table 1) from 160 patients were included, of which 61 (31%) were positive for IE. In total, 36 examinations had negative TTE prior to TOE of which 32 (86%) also had negative TOE. Of the 5 (14%) negative TTE prior to TOE that had positive TOE, all had cardiovascular implantable electronic device (CIED) and/or prosthetic valves.

CONCLUSIONS

The existing recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients being referred for TOE with negative results. Negative TTE examination with good image quality and no CIED or prosthetic valves, may be sufficient without jeopardizing the IE diagnosis.

Subcutaneous implantable cardioverter‐defibrillator: a systematic review of comparative effectiveness and safety

This systematic review evaluated the clinical effectiveness and safety of subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients at an increased risk of sudden cardiac death and with an ICD indication for primary or secondary prevention. A systematic literature search was conducted in four databases (Medline via Ovid, Embase, the Cochrane Library, and HTA-INAHTA). Randomized controlled trials (RCTs) and controlled observational studies with ≥100 S-ICD patients and a low to moderate risk of bias were eligible for inclusion. The studies' quality and the available evidence's strength were assessed using the Cochrane risk of bias tool, the ROBINS-I tool, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. One RCT, a post hoc analysis of the RCT (n = 849) and four controlled observational studies (n = 7149) were included. The quality of the available evidence was graded as low to very low, except for the primary composite endpoint of the RCT, which was rated as moderate quality. After 4 years, the RCT showed that S-ICD was non-inferior to TV-ICD regarding the composite endpoint of inappropriate shocks and device-related complications (68 [15.1%] vs. 68 [15.7%], hazard ratio [HR] 0.99, 95% confidence interval [CI] [0.71, 1.39], non-inferiority margin 1.45, P = 0.001). The RCT and two observational studies reported statistically significantly fewer lead complications in S-ICD patients (after 4 years: 1.4% vs. 6.6%, HR 0.24, 95% CI [0.10, 0.54]; after 3 years: 0.3% vs. 2.3%, P = 0.03; and after 5 years: 0.8% vs. 11.5%, P = 0.03). Identified evidence about appropriate and inappropriate shocks was inconclusive: The RCT detected statistically significantly more appropriate shocks in patients with S-ICD (83 [19.2%] vs. 57 [11.5%], HR 1.52, 95% CI [1.08, 2.12], P = 0.02), whereas one observational study showed a statistically significantly lower rate in the S-ICD group (9.9%, 95% CI [7.0, 13.9], vs. 13.9%, 95% CI [10.8, 17.8], P = 0.003). Regarding inappropriate shocks, one observational study reported statistically significantly higher rates in the S-ICD cohort (11.9% vs. 7.5%, P = 0.007), whereas the RCT and two other observational studies did not detect a statistically significant difference between the treatment groups (P > 0.05). None of the included studies showed a statistically significant difference in overall mortality and shock efficacy between patients with S-ICD and TV-ICD (P > 0.05). The available evidence is insufficient to show the superiority of S-ICD compared with TV-ICD, hindering the widespread use of the technology. Results of the recently completed ATLAS trial are to be awaited, and the anticipated role of the S-ICD needs to be clearly formulated.

Influence of the healthcare pathway on the outcome of patients with infective endocarditis

AIMS

To determine the prognosis of patients treated for infective endocarditis (IE) according to their healthcare pathway. To assess how the ESC guidelines are implemented concerning the performance of transoesophageal echocardiography, the use of antibiotic therapy, and the performance of valve surgery; and to compare the epidemiological profile of IE according to the type of centres in which the patients are hospitalized.

METHODS AND RESULTS

In a prospective multicentric study including 22 hospitals in the South-East of France, 342 patients were classified into three groups according to their healthcare pathway: 119 patients diagnosed and taken care entirely in a reference centre or hospital with cardiac surgery [Referral Center (RC) group], 111 patients diagnosed and initially taken care in a non-RC (NRC), then referred in a centre including cardiac surgery [transferred to the Referral Center (TRC) group] and 112 patients totally taken care in the NRC (NRC group). One-year mortality was 26% (88 deaths) and was not significantly different between Groups 1 and 2 (20 vs. 21%, P = 0.83). Patients in the NRC group had a higher mortality (37%) compared with patients in the RC and TRC groups (P < 0.001). ESC guidelines were not implemented similarly depending on the healthcare pathway (P = 0.04). Patients in the NRC group were significantly older (P < 0.001) and had more comorbidities (P < 0.001) than patients treated in referral centres.

CONCLUSION

Prognosis of patients with IE is influenced by their healthcare pathway. Patients treated exclusively in NRC have a worse prognosis than patients treated in referral or surgical centres.

Impact of therapeutic drug monitoring of antibiotics in the management of infective endocarditis

Treatment of infective endocarditis (IE) is based on high doses of antibiotics with a prolonged duration. Therapeutic drug monitoring (TDM) allows antibiotic prescription optimization and leads to a personalized medicine, but no study evaluates its interest in the management of IE. We conducted a retrospective, bicentric, descriptive study, from January 2007 to December 2019. We included patients cared for IE, defined according to Duke's criteria, for whom a TDM was requested. Clinical and microbiological data were collected after patients' charts review. We considered a trough or steady-state concentration target of 20 to 50 mg/L. We included 322 IE episodes, corresponding to 306 patients, with 78.6% (253/326) were considered definite according to Duke's criteria. Native valves were involved in 60.5% (185/306) with aortic valve in 46.6% (150/322) and mitral in 36.3% (117/322). Echocardiography was positive in 76.7% (247/322) of cases. After TDM, a dosage modification was performed in 51.5% (166/322) (decrease in 84.3% (140/166)). After initial dosage, 46.3% (82/177) and 92.8% (52/56) were considered overdosed, when amoxicillin and cloxacillin were used, respectively. The length of hospital stay was higher for patient overdosed (25 days versus 20 days (p = 0.04)), and altered creatinine clearance was associated with overdosage (p = 0.01). Our study suggests that the use of current guidelines probably leads to unnecessarily high concentrations in most patients. TDM benefits predominate in patients with altered renal function, but probably limit adverse effects related to overdosing in most patients.

Risk factors associated with mortality in the infective endocarditis patients requiring cardiac surgery: a study based on Latvian population

BACKGROUND

Increased life expectancy, developments in medicine and intracardiac devices, accessibility of cardiac surgery, decrease in the prevalence of rheumatic heart disease are changing infective endocarditis patient profile and thus risk factors for the adverse events. This single-center-based study covering the whole Latvian population aimed to assess the intrahospital and 3-year mortality of infective endocarditis patients who underwent cardiac surgery, as well as risk factors and laboratory indices predictive of adverse outcomes of the disease.

METHODS

Clinical profiles, data of laboratory and instrumental analyses, operation and intensive care unit records of cardiac surgery patients treated in Pauls Stradins Clinical University Hospital, Riga, Latvia, between 2015 and 2019 were analyzed.

RESULTS

We analyzed data from 242 episodes of surgically treated infective endocarditis in 233 patients. The median age of patients was 57.00 (45.00-68.00) years. The rate of intrahospital mortality was 11.16%. Risk factors associated with mortality in the univariate analyses were S. aureus infection (HR=2.27, 95% CI: 1.36-3.80; P=0.002) and systemic embolization of vegetations (HR=1.63, 95% CI: 1.00-2.64; P=0.048). Perivalvular complications (HR=1.98, 95% CI: 1.19-3.29; P=0.009) were found to be independently associated with mortality in multivariate analysis (HR=1.99, 95% CI: 1.05-3.78; P=0.035). One-year survival was 78.3%, whereas three-year -71.3%.

CONCLUSIONS

Intrahospital mortality of surgically treated IE patients was 11.2%; however, one- and three-year mortality was 21.7 and 28.7%, respectively. Perivalvular complications were independently associated with mortality. Laboratory indices were not predictive of adverse outcomes.

Visualizing Staphylococcus aureus pathogenic membrane modification within the host infection environment by multimodal imaging mass spectrometry

Bacterial pathogens have evolved virulence factors to colonize, replicate, and disseminate within the vertebrate host. Although there is an expanding body of literature describing how bacterial pathogens regulate their virulence repertoire in response to environmental signals, it is challenging to directly visualize virulence response within the host tissue microenvironment. Multimodal imaging approaches enable visualization of host-pathogen molecular interactions. Here we demonstrate multimodal integration of high spatial resolution imaging mass spectrometry and microscopy to visualize Staphylococcus aureus envelope modifications within infected murine and human tissues. Data-driven image fusion of fluorescent bacterial reporters and matrix-assisted laser desorption/ionization Fourier transform ion cyclotron resonance imaging mass spectrometry uncovered S. aureus lysyl-phosphatidylglycerol lipids, localizing to select bacterial communities within infected tissue. Absence of lysyl-phosphatidylglycerols is associated with decreased pathogenicity during vertebrate colonization as these lipids provide protection against the innate immune system. The presence of distinct staphylococcal lysyl-phosphatidylglycerol distributions within murine and human infections suggests a heterogeneous, spatially oriented microbial response to host defenses.

Unusual Presentation of Infective Endocarditis Following a Prostatic Urethral Lift

Infective endocarditis is a serious inflammation of the inner lining of the heart. It is caused by pathogens entering the bloodstream and infecting the endocardium. We demonstrate a unique presentation of infective endocarditis following a prostatic urethral lift. The low index of suspicion and atypical symptoms prevented early diagnosis of the disease, leading to life-threatening complications and valve replacement surgery. Understanding unusual presentations of infective endocarditis can increase the index of suspicion in outpatient settings, leading to early diagnosis and preventing fatal complications.

Infectious native valve endocarditis by Streptococcus agalactiae species: Case report of pathogen identification only through metagenomic sequencing technology

INTRODUCTION

Streptococcus agalactiae is a common pathogen in infective endocarditis, but the positive rate of traditional blood culture diagnosis is not high. It is challenging to obtain a good outcome in the absence of pathogen information for patients with infectious endocarditis.

PATIENT CONCERNS AND DIAGNOSIS

Here, we report the case of a patient with infective endocarditis caused by S. agalactiae. The initial manifestations of this patient were coma, urinary incontinence, and fecal incontinence and had no history of heart disease or infectious diseases before admission.

INTERVENTIONS AND OUTCOMES

When the blood culture was negative 3 consecutive times, the pathogen S. agalactiae was diagnosed in a timely and accurate manner by metagenome sequencing. Eventually, the patient was discharged following surgery and antibiotic treatment.

CONCLUSIONS

For IE patients with infective endocarditis, metagenome sequencing is a valuable and selective tool for rapid, sensitive, and accurate pathogen detection, especially when the blood culture is negative.

Self and professional treatment of skin and soft tissue infections among women who inject drugs: Implications for wound care provision to prevent endocarditis

Background:

Skin and soft tissue infections (SSTI) are common among people who inject drugs and can result in severe health consequences, including infective endocarditis. Numerous barriers to accessing care often prevent people who inject drugs from seeking healthcare including past negative healthcare experiences, transportation, and shame around drug use. These barriers can lead some people who inject drugs to self-care instead of seeking formal treatment.

Methods:

We explored the prevalence of SSTIs and associated treatment behaviors among women who inject drugs and sell sex (N = 114). Women reported their drug use and SSTI histories. Those who experienced an SSTI reported if they self-treated their SSTIs and/or sought formal treatment.

Results:

Half (50.0%) experienced at least one SSTI in the past 6 months. SSTIs were more common among those who injected painkillers (24.6% vs 8.8%, p = 0.02) and who had ever been treated for endocarditis (28.1% vs 10.5%, p = 0.02). SSTIs were less common among those who injected multiple times per day (17.9% vs 38.6%, p = 0.01) and always injected with a sterile syringe (19.3% vs 42.1%, p = 0.01). Among those who experienced an SSTI, most (85.7%) reported self-treating, and half (52.6%) sought formal care. The emergency room was the most common source of care (73.3%).

Conclusions:

When experiencing SSTIs, women often opted to self-treat rather than seek formal healthcare. A lack of formal care can lead to infections progressing to serious conditions, like endocarditis. Self-treatment with non-prescribed antibiotics may further result in antibiotic-resistant infections. Low threshold, stigma free, community-based wound care programs are warranted.

Modification of Reconstruction of Left Ventricular Outflow Tract, Aortic Root and the Intervalvular Fibrous Body for Extensive Infective Endocarditis: A Single Center Experience

BACKGROUND

Extensive infective endocarditis stays a serious life-threatening disease with high mortality and morbidity. The aim of this study is to analyze our experience with our modified surgical technique for extensive infective endocarditis during the last 4 years.

METHODS

Between March 2017 and February 2021, all patients with extensive infective endocarditis required our modified technique consisting of a radical surgical resection of all infected cardiac tissues, the replacement of infected valves, and a reconstruction of the intervalvular fibrous body, the aortic root and the left ventricular outflow tract with modified elephant trunk were included in this study.

RESULTS

Our modified technique was performed on 41 patients during the study period. The age median was 74 (IQR: 66.5 - 76.5) and 61.0% (n = 25) were female. 33 patients (80.5%) were in New York Heart Association Class III-IV and 7 patients (17.1%) in cardiogenic shock. The median logistic EuroSCORE II as predicted risk of mortality was 35% (IQR: 28% - 78%). Median cardiopulmonary bypass time and cross-clamping time were 126 (IQR: 86.5-191) min and 78 (IQR: 55.5-108) min, respectively. Intraoperative mortality and 30-day mortality were 4.8% (2 patients) and 19.5% (8 patients), respectively. Low cardiac output with necessity for mechanical support, stroke and new renal dialysis developed in 9.8% (4 patients), 17.1% (7 patients), and 22.0% (9 patients), respectively. New pacemaker implantation was noted in 39.0% (16 patients). Intensive care stay and hospital stay had medians of 6 (IQR: 5-12) and 14 (IQR: 12.5-20.5) days, respectively. One-year mortality and 4-years mortality were 34.1% (14 patients) and 39.0% (16 patients), respectively. Kaplan-Meier survival estimates were 60.3% (95% CI: 46.2 - 78.6%) at 3 years.

CONCLUSIONS

Our modified technique can be performed in patients with extensive infective endocarditis with acceptable early and mid-term morbidity and mortality. We believe that this technique is an available option for this ill-fated group of patients.

Characteristics, management, and outcomes of patients with left-sided infective endocarditis complicated by heart failure: A substudy of the ESC-EORP EURO-ENDO (European infective endocarditis) registry

AIMS

To evaluate the current management and survival of patients with left-sided infective endocarditis (IE) complicated by congestive heart failure (CHF) in the ESC-EORP European Endocarditis (EURO-ENDO) registry.

METHODS AND RESULTS

Among the 3116 patients enrolled in this prospective registry, 2449 (mean age:60 years, 69% male) with left-sided (native or prosthetic) IE were included in this study. Patients with CHF (n=698, 28.5%) were older, with more comorbidity and more severe valvular damage (mitro-aortic involvement, vegetations>10mm and severe regurgitation/new prosthesis dehiscence) than those without CHF (all p≤0.019). Patients with CHF experienced higher 30-day and one-year mortality than those without (20.5% vs. 9.0% and 36.1% vs. 19.3%, respectively) and CHF remained strongly associated with 30-day(OR95%CI=2.37[1.73-3.24];p<0.001) and one-year mortality(HR95%CI=1.69[1.40-2.05];p<0.001) after adjustment for established outcome predictors, including early surgery, or after propensity matching for age, sex, and comorbidity(n=618[88.5%] for each group, both p<0.001). Early surgery, performed on 49% of these patients with IE complicated by CHF, remained associated with a substantial reduction in 30-day mortality following multivariable analysis, after adjustment for age, sex, Charlson index, cerebrovascular accident, staphylococcus aureus IE, Streptococcal IE, uncontrolled infection, vegetation size>10mm, severe valvular regurgitation and/or new prosthetic dehiscence, perivalvular complication, and prosthetic IE(OR95%CI=0.22[0.12-0.38];p<0.001) and in one-year mortality(HR95%CI=0.29[0.20-0.41];p<0.001).

CONCLUSION

CHF is common in left-sided IE and is associated with older age, greater comorbidity, more advanced lesions, and markedly higher 30-day and one-year mortality. Early surgery is strongly associated with lower mortality but is performed on only approximately half of patients with CHF, mainly because of a surgical risk considered prohibitive.

The association between systemic inflammatory response index and in-hospital mortality in patients with infective endocarditis

Background

Infective endocarditis (IE) has a significant mortality, and early identification of high‐risk patients and prediction of poor outcomes is of great significance. In recent years, increasing research has revealed the predictors associated with infective endocarditis prognosis. Systemic inflammatory response index (SIRI) is an important new indicator of inflammation. So far, there have been no reports on the relationship between SIRI and the prognosis of IE patients.

Hypothesis

The purpose of this study was to explore the value of SIRI in predicting in‐hospital death for patients with infective endocarditis (IE), so as to provide reference for improving the prognosis of patients with IE.

Method

A retrospective analysis was performed on the clinical data of patients with IE admitted to the First Affiliated Hospital of Nanjing Medical University from January 2017 to December 2019. SIRI was calculated according to the blood routine results of patients at admission; receiver operating characteristic curve was employed to determined the optimal cutoff value of SIRI. Patients were divided into groups (low SIRI group and high SIRI group; nonsurvivor group and survivor group) according to the levels of SIRI or their prognosis, and the general clinical features of the two groups were compared. Univariate and multivariate logistic regression analysis were performed to analyze the independent prognostic factors of in‐hospital death in IE patients.

Results

A total of 147 IE patients meeting the diagnostic criteria were included, including 102 males (69.4%) and 45 females (30.6%). There was statistically significant difference in SIRI level between nonsurvivor group and survivor group (p < .05). After adjusting for the related factors, the risk of in‐hospital death in the high SIRI was still a risk of in‐hospital death with statistical significance (hazard ratio = 5.053, 95% confidence interval: 1.426‒17.905, p = .012).

Conclusions

Higher SIRI level is independently associated with the risk of in‐hospital death in IE patients, and can be an independent predictor of poor outcome in IE patients.

Introduction of the Rapid Deployment Aortic Valve System Use in Elderly Patients With Endocarditis

Introduction

The rapid-deployment valve system (RDVS) was introduced to facility minimally invasive aortic valve replacement. In this study we evaluate the potential benefits of RDVS in elderly high-risk patients with endocarditis of the aortic valve.

Materials and Methods

Since the introduction of RDVS in our institution in December 2017 through October 2021, EDWARDS INTUITY rapid-deployment prosthesis (Model 8300A, Edwards Lifesciences, Irvine, CA, USA) has been implanted in a total of 115 patients for different indications by a single surgeon. Out of one-hundred and fifteen cases of RDVS implantation, seven patients with a median age of 77 yrs. (range 62-84yrs.), suffered from active infective endocarditis of the aortic valve. The median EuroSCORE II of these highly selected patient cohort was 77% (range 19-80%). Patient data were evaluated perioperatively including intra-operative data as well as in-hospital morbidity/mortality and follow-up after discharge from hospital.

Results

Three patients underwent previous cardiac surgery. Concomitant procedures were performed in six patients including, ascending aorta replacement (n = 3), mitral valve repair (n = 1), pulmonary valve replacement (n = 1), bypass surgery (n = 1), left atrial appendix resection (n = 1) and anterior mitral valve repair (n = 1). Median aortic cross-clamp and cardiopulmonary bypass time was 56 min (range 29-122 min) and 81 min (range 45-162 min.), respectively. Post-operative complications in these elderly high-risk patients were atrial fibrillation (n = 3) and re-exploration for pericardial effusion (n = 1). One pacemaker implantation was required on postoperative day 6 due to sick sinus syndrome. There was one in-hospital death (14%) and one during follow-up (14%).

Conclusion

Rapid-deployment aortic valve system seems to be a viable option with acceptable morbidity and mortality in elderly high-risk patients with active infective endocarditis of the aortic valve.

The impact of implementing an endocarditis team in comparison to the classic heart team in a tertiary referral centre

Background

Infective endocarditis (IE) is a complex disease for which the European Society of Cardiology guideline recommends a dedicated multidisciplinary endocarditis team (ET) approach since 2015. It is currently unknown whether this ET approach is beneficial compared to a classic heart team approach including bedside consultation by an infectious disease specialist in Western Europe.

Methods

This retrospective single centre, observational cohort study was conducted at the Radboudumc, a tertiary referral centre in the Netherlands. Consecutive patients treated for IE were included from September 2017 to September 2018 before implementation of a dedicated ET and from May 2019 to May 2020 afterwards.

Results

In total, 90 IE patients (45 patients before and 45 patients after the implementation of the ET) were included. No significant differences were found in diagnostic workup, surgical treatment (surgery performed 69% vs. 71%, p = 0.82), time to surgery because of an urgent indication (median 4 vs. 6 days, p = 0.82), in-hospital complications (53% vs. 67%, p = 0.20), and 6-month mortality (11% vs. 13%, p = 0.75) between IE patients treated before and after the implementation of the ET.

Conclusion

Formalization of the recommended multidisciplinary endocarditis team might not significantly improve the complication rate nor the short term outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02558-0.

Subarachnoid Haemorrhage in a Patient With Suspected Infective Endocarditis in a District General Hospital: A Case Report-Based Literature Review

We describe the case of a 70-year-old lady who presented to a district general hospital during an evening with fevers, feeling generally unwell. She was found to have weakness in her left upper limb and went on to have tonic-clonic seizures whilst in the Accident and Emergency Department. CT scan of the brain showed subarachnoid haemorrhage, in absence of headache, in the right frontal, superior parietal and left occipital regions. Her C-reactive protein level was elevated at 426 mg/L and her urine dip was normal. Chest radiograph showed small bilateral pleural effusions. In addition to the above-mentioned findings on clinical examination, she also had pansystolic murmur although did not have any other feature of infective endocarditis (IE). In view of the above findings, normal chest examination and no urinary symptoms, the decision was made to treat this as a case of IE empirically. She subsequently went into fast atrial fibrillation requiring direct current (DC) cardioversion and intensive care unit admission due to hypotension. The next day, echocardiography confirmed vegetations and blood cultures were positive for Staphylococcus aureus. Her MRI scan of the brain confirmed parenchymal haemorrhages and haemorrhagic infarcts. She completed a 6-week course of antibiotics and clinically improved. Despite being critically unwell, appropriate antibiotics were initiated within hours of her admission in view of clinical suspicion of underlying IE, which aided her recovery.

Successful treatment of canine infective endocarditis caused by Bacillus amyloliquefaciens

Bacillus amyloliquefaciens is a gram-positive bacterial species that is utilised as a probiotic in humans and animals. There are no reports of infective endocarditis (IE) in dogs. An 8-year-old, spayed, female Maltese presented with a 1-month history of fever, depression, weight loss, and hindlimb lameness. Laboratory test results indicated non-regenerative anaemia, neutrophilia, hyperglobulinemia, and proteinuria. Echocardiography revealed vegetation on the septal leaflet of the mitral valve and thromboemboli in the left atrium. Consecutive blood culture results revealed that the blood samples were consistently positive for Bacillus amyloliquefaciens, which is generally considered a probiotic bacterial species for animals. Broad-spectrum antibiotics (amoxicillin-clavulanic acid and cefotaxime) and anticoagulants (clopidogrel and rivaroxaban) were administered for 4 months. The clinical signs were responsive to antibiotic treatment. After 4 months, the dog was no longer febrile and the size of the thromboemboli in the left atrium had decreased. Bacteria were no longer isolated in blood cultures after antibiotic therapy. To the best of our knowledge, this is the first case report of canine IE caused by bactaeremic infection with Bacillus amyloliquefaciens.

What Does 16S rRNA Gene-Targeted Next Generation Sequencing Contribute to the Study of Infective Endocarditis in Heart-Valve Tissue?

Infective endocarditis (IE) is a severe and life-threatening disease. Identification of infectious etiology is essential for establishing the appropriate antimicrobial treatment and decreasing mortality. The aim of this study was to explore the potential utility of metataxonomics for improving microbiological diagnosis of IE. Here, next-generation sequencing (NGS) of the V3-V4 region of the 16S rRNA gene was performed in 27 heart valve tissues (18 natives, 5 intravascular devices, and 4 prosthetics) from 27 patients diagnosed with IE (4 of them with negative blood cultures). Metataxonomics matched with conventional diagnostic techniques in 24/27 cases (88.9%). The same bacterial family was assigned to 24 cases; the same genus, to 23 cases; and the same species, to 13 cases. In 22 of them, the etiological agent was represented by percentages > 99% of the reads and in two cases, by ~70%. Staphylococcus aureus was detected in a previously microbiological undiagnosed patient. Thus, microbiological diagnosis with 16S rRNA gene targeted-NGS was possible in one more sample than using traditional techniques. The remaining two patients showed no coincidence between traditional and 16S rRNA gene-targeted NGS microbiological diagnoses. In addition, 16S rRNA gene-targeted NGS allowed us to suggest coinfections that were supported by clinical data in one patient, and minority records also verified mixed infections in three cases. In our series, metataxonomics was valid for the identification of the causative agents, although more studies are needed before implementation of 16S rRNA gene-targeted NGS for the diagnosis of IE.

Early surgical intervention in culture-negative endocarditis of the aortic valve complicated by abscess in an infant: A case report

BACKGROUND

Surgical therapy of infective endocarditis (IE) involving aortic valves and mitral valves is widespread. However, there are few reports concerning patients with culture-negative endocarditis complicated by the appearance of comorbid valvular perforation and abscess. Therefore, real-time surveillance of changes in cardiac structure and function is critical for timely surgical management, especially in patients who do not respond to medical therapy.

CASE SUMMARY

Here, we report an atypical case in a 9-mo-old infant without congenital heart disease but with symptoms of intermittent fever and macular rashes. Physical examination, laboratory tests, and electrocardiograms suggested a diagnosis of IE, although the result of blood cultures was exactly negative. After treatment with antibiotic drugs, the patient got a transient recovery. On the 9^th day, we proceeded with continuous echocardiogram due to fever again and the results revealed aortic valve abscess with perforation, regurgitation, vegetation, and pericardial effusion. Intraoperative monitoring revealed aortic valve perforation, presence of apothegmatic cystic spaces below the left coronary cusp of the aortic valve, and severe aortic valve regurgitation. Aortic valve repair was performed by autologous pericardial patch plasty. The patient was discharged after 4 wk of treatment and no complications occurred after surgery.

CONCLUSION

Our case demonstrated the necessity of serial echocardiography monitoring for possible adverse symptoms of IE in pediatric patients.

Impact of aortic root repair or replacement in severe destructive aortic valve endocarditis with paravalvular abscesses on long-term survival

OBJECTIVES

Surgical treatment of destructive infective endocarditis consists of extensive debridement followed by root repair or replacement. However, it remains unknown whether 1 is superior to the other. We aimed to analyse whether long-term results were better after root repair or replacement in patients with root endocarditis.

METHODS

A total of 148 consecutive patients with root endocarditis treated with surgery from 1997 to 2020 at our department were included. Patients were divided into 2 groups: aortic root repair (n = 85) or root replacement using xenografts or homografts (n = 63).

RESULTS

Patients receiving aortic root repair showed significantly better long-term survival compared to patients receiving aortic root replacement (log-rank: P = 0.037). There was no difference in terms of freedom from valvular reoperations among both treatment groups (log-rank: P = 0.58). Patients with aortic root repair showed higher freedom from recurrent endocarditis compared to patients with aortic root replacement (log-rank: P = 0.022). Patients with aortic root repair exhibited higher event-free survival (defined as a combination end point of freedom from death, valvular reoperation or recurrent endocarditis) compared to patients receiving aortic root replacement (log-rank: P = 0.022). Age increased the risk of mortality with 1.7% per year. Multi-variable adjusted statistical analysis revealed improved long-term event-free survival after aortic root repair (hazards ratio: 0.57, 95% confidence interval: 0.39-0.95; P = 0.031).

CONCLUSIONS

Aortic root repair and replacement are feasible options for the surgical treatment of root endocarditis and are complementary methods, depending on the extent of infection. Patients with less advanced infection have a more favourable prognosis.

CLINICAL TRIAL REGISTRATION

UN4232 382/3.1 (retrospective study).

Type IV Pili of Streptococcus sanguinis Contribute to Pathogenesis in Experimental Infective Endocarditis

Streptococcus sanguinis is a common cause of infective endocarditis (IE). Efforts by research groups are aimed at identifying and characterizing virulence factors that contribute to the ability of this organism to cause IE. This Gram-positive pathogen causes heart infection by gaining access to the bloodstream, adhering to host extracellular matrix protein and/or platelets, colonizing the aortic endothelium, and incorporating itself into the aortic vegetation. While many virulence factors have been reported to contribute to the ability of S. sanguinis to cause IE, it is noteworthy that type IV pili (T4P) have not been described to be a virulence factor in this organism, although S. sanguinis strains typically encode these pili. Type IV pili are molecular machines that are capable of mediating diverse virulence functions and surface motility. T4P have been shown to mediate twitching motility in some strains of S. sanguinis, although in most strains it has been difficult to detect twitching motility. While we found that T4P are dispensable for direct in vitro platelet binding and aggregation phenotypes, we show that they are critical to the development of platelet-dependent biofilms representative of the cardiac vegetation. We also observed that T4P are required for in vitro invasion of S. sanguinis into human aortic endothelial cells, which indicates that S. sanguinis may use T4P to take advantage of an intracellular niche during infection. Importantly, we show that T4P of S. sanguinis are critical to disease progression (vegetation development) in a native valve IE rabbit model. The results presented here expand our understanding of IE caused by S. sanguinis and identify T4P as an important virulence factor for this pathogen.

IMPORTANCE This work provides evidence that type IV pili produced by Streptococcus sanguinis SK36 are critical to the ability of these bacteria to attach to and colonize the aortic heart valve (endocarditis). We found that an S. sanguinis type IV pili mutant strain was defective in causing platelet-dependent aggregation in a 24-h infection assay but not in a 1-h platelet aggregation assay, suggesting that the type IV pili act at later stages of vegetation development. In a rabbit model of disease, a T4P mutant strain does not develop mature vegetations that form on the heart, indicating that this virulence factor is critical to disease and could be a target for IE therapy.

Prognostic models for mortality after cardiac surgery in patients with infective endocarditis: a systematic review and aggregation of prediction models

BACKGROUND

There are several prognostic models to estimate the risk of mortality after surgery for active infective endocarditis (IE). However, these models incorporate different predictors and their performance is uncertain.

OBJECTIVE

We systematically reviewed and critically appraised all available prediction models of postoperative mortality in patients undergoing surgery for IE, and aggregated them into a meta-model.

DATA SOURCES

We searched Medline and EMBASE databases from inception to June 2020.

STUDY ELIGIBILITY CRITERIA

We included studies that developed or updated a prognostic model of postoperative mortality in patient with IE.

METHODS

We assessed the risk of bias of the models using PROBAST (Prediction model Risk Of Bias ASsessment Tool) and we aggregated them into an aggregate meta-model based on stacked regressions and optimized it for a nationwide registry of IE patients. The meta-model performance was assessed using bootstrap validation methods and adjusted for optimism.

RESULTS

We identified 11 prognostic models for postoperative mortality. Eight models had a high risk of bias. The meta-model included weighted predictors from the remaining three models (EndoSCORE, specific ES-I and specific ES-II), which were not rated as high risk of bias and provided full model equations. Additionally, two variables (age and infectious agent) that had been modelled differently across studies, were estimated based on the nationwide registry. The performance of the meta-model was better than the original three models, with the corresponding performance measures: C-statistics 0.79 (95% CI 0.76-0.82), calibration slope 0.98 (95% CI 0.86-1.13) and calibration-in-the-large -0.05 (95% CI -0.20 to 0.11).

CONCLUSIONS

The meta-model outperformed published models and showed a robust predictive capacity for predicting the individualized risk of postoperative mortality in patients with IE.

PROTOCOL REGISTRATION

PROSPERO (registration number CRD42020192602).

Spontaneous spondylodiscitis and endocarditis: interdisciplinary experience from a tertiary institutional case series and proposal of a treatment algorithm

Previously, the simultaneous presence of endocarditis (IE) has been reported in 3–30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82 ± 4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n = 13/36 vs. S n = 57/292, p < 0.05 and chronic heart failure n = 11/36 vs. S n = 41/292, p < 0.05, chronic renal failure SIE n = 14/36 vs. S n = 55/292, p < 0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S = 4.5 ± 4.5 days vs. SIE = 8.9 ± 9.5 days, p < 0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome.

Diagnostic Value of 18F-Fluorodeoxyglucose Positron Emission Tomography Computed Tomography in Prosthetic Pulmonary Valve Infective Endocarditis

OBJECTIVES

The aim of this study was to assess the diagnostic performances of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/computed tomography (CT) in congenital heart disease (CHD) patients with pulmonary prosthetic valve or conduit endocarditis (PPVE) suspicion.

BACKGROUND

PPVE is a major issue in the growing CHD population. Diagnosis is challenging, and usual imaging tools are not always efficient or validated in this specific population. Particularly, the diagnostic yield of ¹⁸F-FDG PET/CT remains poorly studied in PPVE.

METHODS

A retrospective multicenter study was conducted in 8 French tertiary centers. Children and adult CHD patients who underwent ¹⁸F-FDG PET/CT in the setting of PPVE suspicion between January 2010 and May 2020 were included. The cases were initially classified as definite, possible, or rejected PPVE regarding the modified Duke criteria and finally by the Endocarditis Team consensus. The result of ¹⁸F-FDG PET/CT had been compared with final diagnosis consensus used as gold-standard in our study.

RESULTS

A total of 66 cases of PPVE suspicion involving 59 patients (median age 23 years, 73% men) were included. Sensitivity, specificity, positive predictive value, and negative predictive value of ¹⁸F-FDG PET/CT in PPVE suspicion were respectively: 79.1% (95% CI: 68.4%-91.4%), 72.7% (95% CI: 60.4%-85.0%), 91.9% (95% CI: 79.6%-100.0%), and 47.1% (95% CI: 34.8%-59.4%). ¹⁸F-FDG PET/CT findings would help to correctly reclassify 57% (4 of 7) of possible PPVE to definite PPVE.

CONCLUSIONS

Using ¹⁸F-FDG PET/CT improves the diagnostic accuracy of the Duke criteria in CHD patients with suspected PPVE. Its high positive predictive value could be helpful in routine to shorten diagnosis and treatment delays and improve clinical outcomes.