Fungal prosthetic aortic valve endocarditis and endarteritis: An unusual cause of aortic root vegetations

Fungal endocarditis is a relatively rare occurrence with high morbidity and mortality. Patients may have an indolent and non-specific course requiring a high index of suspicion to make a diagnosis. Here, we present the case of a 33-year-old patient who presented with fevers and acute lower limb ischemia requiring a 4-compartment fasciotomy caused by septic emboli from Candida albicans endocarditis. The patient had a large vegetation in the ascending aorta associated with a mycotic aneurysm, which is an exceedingly rare location for a vegetation. We also review the literature and summarize the typical echocardiographic appearance and vegetation locations in fungal endocarditis.

Fungal endocarditis after transcatheter aortic valve replacement (TAVR): Case report and review of literature

The reported number of transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) cases has been increasing worldwide, but information about the incidence and clinical features of fungal TAVR-IE is quite limited. We present a patient who acquired TAVR-IE caused by Candida parapsilosis four month after TAVR, who was successfully treated redo-aortic valve replacement and prolonged antifungal therapy.

Candida endocarditis: systematic literature review from 1997 to 2014 and analysis of 29 cases from the Italian Study of Endocarditis

INTRODUCTION

Candida Endocarditis (CE) is a deadly disease. It is of paramount importance to assess risk factors for acquisition of both Candida native (NVE) and prosthetic (PVE) valve endocarditis and relate clinical features and treatment strategies with the outcome of the disease. Areas covered: We searched the literature using the Pubmed database. Cases of CE from the Italian Study on Endocarditis (SEI) were also included. Overall, 140 cases of CE were analyzed. Patients with a history of abdominal surgery and antibiotic exposure had higher probability of developing NVE than PVE. In the PVE group, time to onset of CE was significantly lower for biological prosthesis compared to mechanical prosthesis. In the whole population, greater age and longer time to diagnosis were associated with increased likelihood of death. Patients with effective anti-biofilm treatment, patients who underwent cardiac surgery and patients who were administered chronic suppressive antifungal treatment showed increased survival. For PVE, moderate active anti-biofilm and highly active anti-biofilm treatment were associated with lower mortality. Expert commentary: Both NVE and PVE could be considered biofilm-related diseases, pathogenetically characterized by Candida intestinal translocation and initial transient candidemia. Cardiac surgery, EAB treatment and chronic suppressive therapy might be crucial in increasing patient survival.

Infective endocarditis in patients with an implanted transcatheter aortic valve: Clinical characteristics and outcome of a new entity

AIMS

This study reports one case and review the literature on TAVI-associated endocarditis (TAVIE), to describe its clinical picture and to perform an analysis on prognostic factors.

METHODS AND RESULTS

A MEDLINE search from January 2002 to October 2014 revealed 31 cases of TAVIE, including 1 from our hospital. Median age was 81 years (IQR, 78-85), 53% of patients were males and the median age-adjusted Charlson score was 7 (IQR, 5-8). Heart failure was recorded in 42%, embolic events in 19%, and periannular complications in 45%. The most common causative agent was Enterococcus spp (36%). Ten patients (32%) underwent surgery and nine patients died (29%). The prognostic factors for 6-month mortality were heart failure (HR, 9.97 [3.7-24.5]; p = 0.001), periannular complications (HR, 11.82 [3.3-41.3]; p = 0.004), and nonenterococcal/streptococcal etiology (HR, 4.76 [2.1-11.1]; p = 0.03). In patients with heart failure who did not undergo surgery, mortality was 89% (8 out of 9); in those who did undergo surgery, mortality was 0% (p < 0.001).

CONCLUSIONS

TAVIE is an emerging entity with high mortality. Patients with heart failure who did not undergo surgery had a higher probability of dying. Surgical treatment provided better outcomes even in patients in whom surgery had previously been ruled out.

Prosthetic valve endocarditis with valvular obstruction after transcatheter aortic valve replacement

Patients with severe aortic stenosis who are at high risk for open-heart surgery might be candidates for transcatheter aortic valve replacement (TAVR). To our knowledge, this is the first report of Streptococcus viridans endocarditis that caused prosthetic valve obstruction after TAVR. A 77-year-old man who had undergone TAVR 17 months earlier was admitted because of evidence of prosthetic valve endocarditis. A transthoracic echocardiogram revealed a substantial increase in the transvalvular peak gradient and mean gradient in comparison with an echocardiogram of 7 months earlier. A transesophageal echocardiogram showed a 1.5-cm vegetation obstructing the valve. Blood cultures yielded penicillin-sensitive S. viridans. The patient was hemodynamically stable and was initially treated with vancomycin because of his previous penicillin allergy. Subsequent therapy with levofloxacin, oral penicillin (after a negative penicillin skin test), and intravenous penicillin eliminated the symptoms of the infection. Transcatheter aortic valve replacement is a relatively new procedure, and sequelae are still being discovered. We recommend that physicians consider obstructive endocarditis as one of these.

Antimicrobial effects of silver zeolite, silver zirconium phosphate silicate and silver zirconium phosphate against oral microorganisms

OBJECTIVE

To evaluate the antimicrobial activities of silver inorganic materials, including silver zeolite (AgZ), silver zirconium phosphate silicate (AgZrPSi) and silver zirconium phosphate (AgZrP), against oral microorganisms. In line with this objective, the morphology and structure of each type of silver based powders were also investigated.

METHODS

The antimicrobial activities of AgZ, AgZrPSi and AgZrP were tested against Streptococcus mutans, Lactobacillus casei, Candida albicans and Staphylococcus aureus using disk diffusion assay as a screening test. The minimum inhibitory concentration (MIC) and minimum lethal concentration (MLC) were determined using the modified membrane method. Scanning electron microscope and X-ray diffraction were used to investigate the morphology and structure of these silver materials.

RESULTS

All forms of silver inorganic materials could inhibit the growth of all test microorganisms. The MIC of AgZ, AgZrPSi and AgZrP was 10.0 g/L whereas MLC ranged between 10.0-60.0 g/L. In terms of morphology and structure, AgZrPSi and AgZrP had smaller sized particles (1.5-3.0 µm) and more uniformly shaped than AgZ.

CONCLUSIONS

Silver inorganic materials in the form of AgZ, AgZrPSi and AgZrP had antimicrobial effects against all test oral microorganisms and those activities may be influenced by the crystal structure of carriers. These results suggest that these silver materials may be useful metals applied to oral hygiene products to provide antimicrobial activity against oral infection.

Infective endocarditis in the transcatheter aortic valve replacement era: comprehensive review of a rare complication

In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a revolutionary alternative for surgical aortic valve replacement (SAVR) for the treatment of severe symptomatic aortic stenosis in patients at high risk for surgery. Prosthetic aortic valve endocarditis is a serious complication after SAVR with high morbidity and mortality. Although numerous TAVR procedures have been performed worldwide, infective endocarditis (IE) after TAVR was reported in the literature in few cases only and in 0% to 2.3% of patients enrolled in large TAVR cohorts. Our aim was to review the literature for IE following TAVR and to discuss the diagnostic and management strategies of this rare complication. Ten case reports of IE after TAVR were identified, 8 of which were published as case reports and 2 of which were presented in congresses. Infective endocarditis occurred in a mean time period of 186 days (median, 90 days) after TAVR. Most cases were characterized by fever and elevated inflammatory markers. Infective endocarditis after TAVR shared some common characteristics with IE after SAVR, yet it has some unique features. Echocardiographic findings included leaflet vegetations, severe mitral regurgitation with rupture of the anterior leaflet, and left ventricle outflow tract to left atrium fistula. Bacteriologic findings included several atypical bacteria or fungi. Cases of IE were managed either conservatively by antibiotics and/or using surgery, and the overall prognosis was poor. Infective endocarditis after TAVR deserves prompt diagnosis and treatment. Until further evidence is present, IE after TAVR should be managed according to SAVR guidelines with modifications as needed on a case-by-case basis.