Clinical profile and outcome of recurrent infective endocarditis

Infective endocarditis

First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

Survival and Recurrence of Endocarditis following Mechanical vs. Biological Aortic Valve Replacement for Endocarditis in Patients Aged 40 to 65 Years: Data from the INFECT-Registry

BACKGROUND

Infective endocarditis (IE) is a serious disease, and in many cases, surgery is necessary. Whether the type of prosthesis implanted for aortic valve replacement (AVR) for IE impacts patient survival is a matter of debate. The aim of the present study is to quantify differences in long-term survival and recurrence of endocarditis AVR for IE according to prosthesis type among patients aged 40 to 65 years.

METHODS

This was an analysis of the INFECT-REGISTRY. Trends in proportion to the use of mechanical prostheses versus biological ones over time were tested by applying the sieve bootstrapped t-test. Confounders were adjusted using the optimal full-matching propensity score. The difference in overall survival was compared using the Cox model, whereas the differences in recurrence of endocarditis were evaluated using the Gray test.

RESULTS

Overall, 4365 patients were diagnosed and operated on for IE from 2000 to 2021. Of these, 549, aged between 40 and 65 years, underwent AVR. A total of 268 (48.8%) received mechanical prostheses, and 281 (51.2%) received biological ones. A significant trend in the reduction of implantation of mechanical vs. biological prostheses was observed during the study period (p < 0.0001). Long-term survival was significantly higher among patients receiving a mechanical prosthesis than those receiving a biological prosthesis (hazard ratio [HR] 0.546, 95% CI: 0.322-0.926, p = 0.025). Mechanical prostheses were associated with significantly less recurrent endocarditis after AVR than biological prostheses (HR 0.268, 95%CI: 0.077-0.933, p = 0.039).

CONCLUSIONS

The present analysis of the INFECT-REGISTRY shows increased survival and reduced recurrence of endocarditis after a mechanical aortic valve prosthesis implant for IE in middle-aged patients.

Infective Endocarditis in an Intravenous Drug User Leading to Myocardial Rupture and Hemopericardium

Introduction

Infective endocarditis (IE) is an infectious disorder of the innermost lining of the heart that can be fatal if left untreated. Infective endocarditis can spread beyond the endocardium into the myocardium and cause arrhythmias and myocardial wall rupture. Individuals with a history of intravenous drug use are at increased risk of developing IE and are at higher risk of dying, given their limited access to health care and adherence to treatment.

Methods

A medicolegal autopsy was performed on a 30-year-old woman with a history of intravenous drug use and recent assault after a hospital admission during which she did not survive resuscitation.

Results

The cause of death was found to be myocardial rupture in the setting of transmural IE. Postmortem imaging showed hemopericardium which was identified grossly with valvular vegetations in the heart. A ventricular wall defect along with transmural abscess formation was identified. Perimortem toxicology was positive for fentanyl, methamphetamine, and benzoylecgonine, a metabolite of cocaine. Postmortem blood cultures were positive for coagulase-negative Staphylococci, Staphylococcus aureus, Candida tropicalis, and Viridians group Streptococci. Postmortem tissue cultures taken from the heart was positive for Candida glabrata and Streptococcus mitis.

Discussion

The decedent had significant risk factors for IE, such as intravenous drug use and a prior admission to hospital for IE. The organisms identified on culture are in-keeping with the gross findings of IE and the terminal event of myocardial rupture was likely the result of tissue damage resulting from IE.