Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias

Acute Decompensated Valvular Disease in the Intensive Care Unit

Acute decompensated valvular disease encompasses a group of complex and challenging conditions, which are often the primary reason for admission to the cardiac intensive care unit and can also complicate the management of other primary cardiac disorders. Critically ill patients with valvular disease also present unique diagnostic and management challenges. Historically, medical and percutaneous interventional therapies have been limited and surgery was the only definitive treatment; however, surgical risk can at times be prohibitive. High-quality evidence to direct management of acute valvular disorders in this population is lacking and societal guidelines largely do not address treatment options for critically ill patients with decompensated valvular disease. In this review, we discuss the clinical presentation and epidemiology of commonly encountered valvular diseases in the modern cardiac intensive care unit, highlight key pathophysiology, detail gaps in evidence, describe the pivotal role of multidisciplinary Heart Teams, and provide guidance for management.

Heartfelt Impact: A Descriptive Analysis of Ceftaroline-Containing Regimens in Endocarditis due to Methicillin-Resistant Staphylococcus aureus

INTRODUCTION

Infective endocarditis (IE) due to methicillin-resistant Staphylococcus aureus (MRSA) is characterized by frequent treatment failure to first-line agents and high mortality, necessitating use of alternative management strategies. Ceftaroline fosamil (CPT) is a cephalosporin antibiotic with activity against MRSA but without regulatory approval for the indication of IE. This study describes clinical experience with CPT-based regimens utilized in MRSA-IE.

METHODS

This is a retrospective, observational, descriptive analysis of patients from two major urban medical centers in Detroit, Michigan from 2011 to 2023. Included adult patients (≥ 18 years) had ≥ 1 positive blood culture for MRSA, met definitive clinical criteria for IE, and received CPT for ≥ 72 h. The primary outcome was treatment failure, defined as a composite of 30-day all-cause mortality from index culture or failure to improve or resolve infectious signs/symptoms after CPT initiation.

RESULTS

Seventy patients were included. The median (interquartile range [IQR]) age was 51 (34-63) years and 45.7% were male. Persons with injection drug use (PWID) made up 55.7% of the cohort and right-sided IE was the most prevalent subtype (50.0%). CPT was frequently employed second-line or later, often in combination with vancomycin (10.0%) or daptomycin (72.9%). Overall, 31.4% experienced treatment failure and 30-day all-cause mortality occurred in 15.7%.

CONCLUSIONS

These findings illustrate the challenges posed by MRSA-IE, including frequent treatment failures, and highlight the utilization of CPT as salvage therapy. Comparative studies are needed to more clearly define its role in MRSA-IE.

Early Valve Surgery for Endocarditis After Acute Embolic Stroke

BACKGROUND

Patients with active endocarditis often suffer acute stroke, with increased risk for hemorrhagic conversion at the time of valve repair or replacement. Controversy persists about timing of operative intervention.

METHODS

An institutional Society of Thoracic Surgeons database of all patients with endocarditis was reviewed for patients undergoing valve surgery (2016-2024). Electronic medical records were reviewed for detailed stroke information and longitudinal follow-up. Descriptive statistics and Kaplan-Meier survival curves evaluated outcomes and survival.

RESULTS

Operations for acute active infective endocarditis were performed in 656 patients. Preoperative stroke occurred in 98 patients (14.9%); 86 strokes (87.8%) were embolic, and 16 patients (18.6%) had microhemorrhagic and 12 (12.2%) had hemorrhagic strokes. Median time between preoperative stroke diagnosis and surgery was 5.5 days. The overall incidence of postoperative stroke was 2.1% (14 of 656), with no statistically significant difference in postoperative stroke between patients with vs without preoperative stroke (n = 4 of 98 [4.1%] vs n = 10 of 558 [1.8%]; P = .148). However, the proportion of patients with postoperative hemorrhagic strokes was higher in the preoperative stroke group (3.1% vs 0.5%, P = .016). Finally, of patients with preoperative stroke, early surgery ≤72 hours (n= 38 [38.8%]) was not associated with increased stroke (2.6% vs 5.0%, P = .564).

CONCLUSIONS

These contemporary data highlight the feasibility of an early valve surgery strategy for acute endocarditis in the setting of acute stroke, with noninferior postoperative stroke risk.

Preoperative fibrinogen level predicts the risk and prognosis of patients with native valve infective endocarditis undergoing valve surgery

Aim

The aim of this study was to assess the clinical significance and prognostic value of the preoperative fibrinogen (FBG) level in patients with native valve infective endocarditis (NVIE) who underwent valve surgery.

Methods

This retrospective study included a total of 163 consecutive patients who were diagnosed with NVIE and underwent valve surgery from January 2019 to January 2022 in our hospital. The primary endpoint was all-cause mortality.

Results

All-cause mortality was observed in 9.2% of the patients (n = 15). Body mass index (BMI) was lower in the survival group (p = 0.025), whereas FBG (p = 0.008) and platelet count (p = 0.044) were significantly greater in the survival group than in the death group. Multivariate Cox proportional hazards analysis revealed that FBG (HR, 0.55; 95% CI, [0.32-0.94]; p = 0.029) was an independent prognostic factor for all-cause mortality. Furthermore, Kaplan‒Meier survival curve analysis revealed that patients with low FBG levels (<3.28 g/L) had a significantly greater mortality rate (p = 0.034) than did those with high FBG levels (>3.99 g/L). In the trend analysis, the FBG tertiles were significantly related to all-cause mortality in all three adjusted models, and the p values for trend were 0.017, 0.016, and 0.028, respectively.

Conclusion

Preoperative FBG may serve as a prognostic factor for all-cause mortality, and an FBG concentration less than 3.28 g/L was associated with a greater risk of all-cause mortality in NVIE patients undergoing valve surgery.

Infective endocarditis outcomes at a tertiary hospital in Western Australia: a retrospective cohort study from 2016 to 2021

BACKGROUND

Infective endocarditis (IE) is a severe infection with considerable mortality. It is associated with geographical variation, complicating diagnosis and treatment of patients in a standardised manner.

AIM

To evaluate the characteristics and management outcomes of patients with IE in Royal Perth Hospital (RPH).

METHODS

A single-centre, retrospective cohort study. Data were collected from medical records of 131 patients with a diagnosis of IE admitted to RPH between 2016 and 2021.

RESULTS

Eighty-four patients with definite IE were included for analysis. The median age of patients was 51.5 years and 77.4% were male. Compared to the general Australian population, there was disproportionately greater representation of Indigenous Australians (21.4%), those with a history of injecting drug use (IDU) (27.4%), rheumatic heart disease (14.3%) and previous IE (13.1%). The most commonly affected valve was the mitral valve in 46.4% of patients, and the most common pathogen was Staphylococcus aureus in 47.6% of patients. Twelve-month mortality was 16.7%, with significantly increased mortality in those treated non-surgically (25.6% vs 7.3%, P = 0.025). Factors associated with undergoing surgery included the presence of aortic valve disease, perivalvular extension of infection and infection with Enterococcus faecalis, whereas IDU, tricuspid valve disease and S. aureus infection were associated with non-surgical management. Adherence to multidisciplinary team review was 75.0%, and surgical management was performed in 70.7% of patients meeting an indication for surgery.

CONCLUSION

IE mortality rates remain high, particularly in patients who do not undergo surgical management. Streamlined MDT assessment and referral for surgical management where appropriate is necessary to improve outcomes.

Trend in Infective Endocarditis in Bulgaria: Characteristics and Outcome, 17-Years, Single Center Experience

BACKGROUND

Infective endocarditis (IE) remains a difficult disease to diagnose and treat, with a persistently high mortality rate. There is a lack of recent data on IE in Bulgaria over the last decades.

METHODS

This study is retrospective, single-centered, and includes 270 patients diagnosed with IE for the period 2005-2021. We compared two periods, 2005-2015 (n = 119) and 2016-2021 (n = 151), to find the characteristics changes.

RESULTS

The study included 177 (65.5%) male patients. In the second period, there is a significant increase in age from 62 (44-73) to 67 (53-75), (p = 0.023); in the Charlson comorbidities index (CCI) from 3 (1-4) to 4 (2-6), (p = 0.000); in cases with chronic kidney diseases (CKDs) from 15 (12.6%) to 55 (36.9%), (p = 0.001); coronary arterial diseases (CADs) from 20 (16.85%) to 44 (29.1%), (p = 0.018); and atrial fibrillation (AF) from 13 (10.9%) to 36 (23.8%), (p = 0.006). Ejection fraction decreased significantly in the second period from 63 (56-70) to 59 (51-66), (p = 0.000). Almost half of the patients 123 (45.6%) had no known predisposing cardiac condition, and 125 (46.3%) had an unknown port of entry. IE was community-acquired in 174 (64.4%), healthcare-associated in 72 (26.7%), and injection-drug-use-related IE in 24 (8.9%). The study population included 183 (67.8%) native valve IE, 85 (31.5%) prosthetic IE, and 2 (0.74%) intracardiac-device-related IE. The hemocultures were positive in 159 (59.6%), and the most frequent pathogenic agent was staphylococci-89 (33.3%) (Staphylococcus aureus-44 (16.5%) and coagulase negative staphylococci-45 (16.8%)). Only 54 (20%) of patients underwent early surgery. The all-cause 30-day mortality rate was 67 (24.8%). There is no significant difference between the two periods in terms of the characteristics listed above.

CONCLUSIONS

The profile of IE in Bulgaria has changed with increasing age and comorbidity, changing predisposing cardiac conditions, and entry door. The most common pathogen was the Staphylococcus spp. The 30-day mortality rate remains high.

Minimally Invasive Surgery through Right Mini-Thoracotomy for Mitral Valve Infective Endocarditis: Contraindicated or Safely Possible?

Background: Mitral valve infective endocarditis (IE) still has a high mortality. Minimally invasive mitral valve surgery (MIMVS) is technically more challenging, especially in patients with endocarditis. Here, we compare the early postoperative outcome of patients with endocarditis and other indications for MIMVS. Methods: Two groups were formed, one consisting of patients who underwent surgery because of mitral valve endocarditis (IE group: n = 75) and the other group consisting of patients who had another indication for MIMVS (non-IE group: n = 862). Patients were observed for 30 postoperative days. Data were retrospectively reviewed and collected from January 2011 to September 2023. Results: Patients from the IE group were younger (60 vs. 68 years; p < 0.001) and had a higher preoperative history of stroke (26% vs. 6%; p < 0.001) with neurological symptoms (26% vs. 9%; p < 0.001). No difference was seen in overall surgery time (211 vs. 206 min; p = 0.71), time on cardiopulmonary bypass (137 vs. 137 min; p = 0.42) and aortic clamping time (76 vs. 78 min; p = 0.42). Concerning postoperative data, the IE group had a higher requirement of erythrocyte transfusion (2 vs. 0; p = 0.041). But no difference was seen in the need for a mitral valve redo procedure, bleeding, postoperative stroke, cerebral bleeding, new-onset dialysis, overall intubation time, sepsis, pacemaker implantation, wound healing disorders and 30-day mortality. Conclusions: Minimally invasive mitral valve surgery in patients with mitral valve endocarditis is feasible and safe. Infective endocarditis should not be considered as a contraindication for MIMVS.

Haemophilus parainfluenza-Associated Aortic Root Abscess and Septic Embolic Stroke Post-transcatheter Aortic Valve Replacement: A Case Study

We present a rare instance of aortic root abscess and septic embolic stroke due to Haemophilus parainfluenza in a 75-year-old male patient who had undergone a recent transcatheter aortic valve replacement. The patient initially presented with generalized weakness and altered mental status. Blood cultures grew Haemophilus parainfluenza. Brain imaging showed multiple infarcts with some areas of hemorrhagic conversion. Echocardiography demonstrated an aortic root abscess as well as vegetation on the tricuspid valve. Surgical correction was deemed high risk; hence, management involved intravenous (IV) antibiotics, resulting in the resolution of both symptoms and the abscess.

Perioperative risk stratification scores in infective endocarditis and its usefulness

Infective endocarditis continues to represent a serious disease worldwide with high morbidity and mortality rates despite advances in diagnosis and treatment. Risk assessment plays a pivotal role in determining the appropriate course of treatment for patients diagnosed with infective endocarditis. In this context, specific endocarditis risk scores have been developed trying to help in the risk assessment process. During the last 15 years, 19 specific endocarditis scores have been published. These newly created scores are very heterogenous in their characteristics, factors included, and validation strategies. The purpose of this review is to analyze the published specific infective endocarditis risk scores and discuss their advantages, limitations, and usefulness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01644-y.

Impact of postoperative cerebral complications in acute infective endocarditis: a retrospective single-center study

BACKGROUND

The treatment of patients with infective endocarditis (IE) who have preoperative cerebral complications remains less understood. Therefore, this study aimed to retrospectively evaluate the clinical outcomes of patients with acute IE based on preoperative intracranial findings.

METHODS

Of 32 patients with acute IE treated at our hospital between August 2015 and March 2022, 31 patients of whom preoperative intracranial imaging evaluation was available were included in our analysis and compared with those with and without intracranial findings. We controlled the mean arterial blood pressure and activated clotting time (ACT) to prevent abnormally high perfusion pressures and ACTs during cardiopulmonary bypass (CPB). The preoperative background, and postoperative courses focusing on postoperative brain complications were reviewed.

RESULTS

Among the 31 patients, 20 (65%) had preoperative imaging findings. The group with intracranial findings was significantly older, with more embolisms in other organs, positive intraoperative pathology findings, and longer CPB times. A new cerebral hemorrhage developed postoperatively in one patient without intracranial findings. There were no early deaths; two patients had recurrent infections in each group, and one died because of sepsis in the late phase in the group with intracranial findings.

CONCLUSIONS

Positive intracranial findings indicated significantly active infectious conditions preoperatively but did not affect the postoperative course. Patients without preoperative cerebral complications can develop serious cerebral hemorrhage. Although meticulous examination of preoperative cerebral complications in all patients with IE is essential, a strategy should be adopted to prevent cerebral hemorrhage, even in patients without intracranial findings.

Effects of a mastitis J5 bacterin vaccination on the productive performance of dairy cows: An observational study using propensity score matching techniques

Inferring causal effects between variables when utilizing observational data is challenging due to confounding factors not controlled through a randomized experiment. Propensity score matching can decrease confounding in observational studies and offers insights about potential causal effects of prophylactic management interventions such as vaccinations. The objective of this study was to determine potential causality and impact of vaccination with an Escherichia coli J5 bacterin on the productive performance of dairy cows applying propensity score matching techniques to farm-recorded (e.g., observational) data. Traits of interest included 305-d milk yield (MY305), 305-d fat yield (FY305), 305-d protein yield (PY305), and somatic cell score (SCS). Records from 6,418 lactations generated by 5,121 animals were available for the analysis. Vaccination status of each animal was obtained from producer-recorded information. Confounding variables considered were herd-year-season groups (56 levels), parity (5 levels: 1, 2, 3, 4, and ≥5), and genetic quartile groups (4 levels: top 25% through bottom 25%) derived from genetic predictions for MY305, FY305, PY305, and SCS, as well as for the genetic susceptibility to mastitis. A logistic regression model was applied to estimate the propensity score (PS) for each cow. Subsequently, PS values were used to form pairs of animals (1 vaccinated with 1 unvaccinated control), depending on their PS similarities (difference in PS values of cows within a match required to be <20% of 1 standard deviation of the logit of PS). After the matching process, 2,091 pairs of animals (4,182 records) remained available to infer the causal effects of vaccinating dairy cows with the E. coli J5 bacterin. Causal effects estimation was performed using 2 approaches: simple matching and a bias-corrected matching. According to the PS methodology, causal effects of vaccinating dairy cows with a J5 bacterin on their productive performance were identified for MY305. The simple matched estimator suggested that vaccinated cows produced 163.89 kg more milk over an entire lactation when compared with nonvaccinated counterparts, whereas the bias-corrected estimator suggested that such increment in milk production was of 150.48 kg. Conversely, no causal effects of immunizing dairy cows with a J5 bacterin were identified for FY305, PY305, or SCS. In conclusion, the utilization of PS matching techniques applied to farm-recorded data was feasible and allowed us to identify that vaccination with an E. coli J5 bacterin relates to an overall milk production increment without compromising milk quality.

Microbiological Etiology in Patients with IE Undergoing Surgery and for Patients with Medical Treatment Only: A Nationwide Study from 2010 to 2020

Microbiological etiology has been associated with surgery for infective endocarditis (IE) during admission, especially Staphylococcus aureus. We aimed to compare patient characteristics, microbiological characteristics, and outcomes by treatment choice (surgery or not). We identified patients with first-time IE between 2010 and 2020 and examined the microbiological etiology of IE according to treatment choice. To identify factors associated with surgery during initial admission, we used the Aalen-Johansen estimator and an adjusted cause-specific Cox model. One-year mortality stratified by microbiological etiology and treatment choice was assessed using unadjusted Kaplan-Meier estimates and an adjusted Cox proportional hazard model. A total of 6255 patients were included, of which 1276 (20.4%) underwent surgery during admission. Patients who underwent surgery were younger (65 vs. 74 years) and less frequently had cerebrovascular disease, cardiovascular disease, diabetes, and chronic kidney disease. Patients with Staphylococcus aureus IE were less likely to undergo surgery during admission (13.6%) compared to all other microbiological etiologies. One-year mortality according to microbiological etiology in patients who underwent surgery was 7.0%, 5.3%, 5.5%, 9.6%, 13.2, and 11.2% compared with 24.2%, 19.1%, 27,6%, 25.2%, 21%, and 16.9% in patients who received medical therapy for Staphylococcus aureus, Streptococcus spp., Enterococcus spp., coagulase-negative Staphylococci, "other microbiological etiologies", and blood culture-negative infective endocarditis, respectively. Patients with IE who underwent surgery differed in terms of microbiology, more often having Streptococci than those who received medical therapy. Contrary to expectations, Staphylococcus aureus was more common among patients who received medical therapy only.

Impact of transfer to reference centres and surgical timing on the prognosis of surgically treated patients with infective endocarditis: a prospective multi-centre cohort study

OBJECTIVES

To compare outcomes in patients with infective endocarditis (IE) first treated in secondary hospitals and then transferred to reference centres for surgery with those in patients diagnosed in reference centres, and to evaluate the impact of surgery timing on prognosis.

METHODS

Analysis of a prospective cohort of patients with active IE admitted to three reference centres between 1996 and 2022 who underwent cardiac surgery in the first month after diagnosis. Multi-variable analysis was performed to evaluate the impact of transfer to reference centres and time to surgery on 30-day mortality. Adjusted ORs with 95% CIs were calculated.

RESULTS

Amongst 703 patients operated on for IE, 385 (54.8%) were referred cases. All-cause 30-day mortality did not differ significantly between referred patients and those diagnosed at reference centres (102/385 [26.5%] vs. 78/385 [24.5%], respectively; p 0.552). Variables independently associated with 30-day mortality in the whole cohort were diabetes (OR, 1.76 [95% CI, 1.15-2.69]), chronic kidney disease (OR, 1.83 [95% CI, 1.08-3.10]), Staphylococcus aureus (OR, 1.88 [95% CI, 1.18-2.98]), septic shock (OR, 2.76 [95% CI, 1.67-4.57]), heart failure (OR, 1.41 [95% CI, 0.85-2.11]), acute renal failure before surgery (OR, 1.76 [95% CI, 1.15-2.69]), and the interaction between transfer to reference centres and surgery timing (OR, 1.18 [95% CI, 1.03-1.35]). Amidst referred patients, time from diagnosis to surgery longer than a week was independently associated with 30-day mortality (OR, 2.19 [95% CI, 1.30-3.69]; p 0.003).

CONCLUSION

Among referred patients, surgery performed >7 days after diagnosis was associated with two-fold higher 30-day mortality.

Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation

Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.

Dismal prognosis of patients with operative indication without surgical intervention in active left-sided infective endocarditis

Introduction

Around 25% of patients with left-sided infective endocarditis and operative indication do not undergo surgery. Baseline characteristics and outcomes are underreported. This study describes characteristics and outcomes of surgical candidates with surgical intervention or medical treatment only.

Methods

Retrospective analysis of ongoing collected data from a single-center from an observational cohort of patients with infective endocarditis (ENVALVE). Kaplan-Meier estimates for survival was calculated. Factors associated with survival were assessed using a bivariable Cox model. To adjust for confounding by indication, uni- and multivariable logistic regression for the propensity to receive surgery were adjusted.

Results

From January 2018 and December 2021, 154 patients were analyzed: 116 underwent surgery and 38 received medical treatment only. Surgical candidates without surgery were older (70 vs. 62 years, p = 0.001). They had higher preoperative risk profile (EuroSCORE II 14% (7.2-28.6) vs. 5.8% (2.5-20.3), p = 0.002) and more comorbidities. One patient was lost-to-follow-up. Survival analysis revealed a significant higher one-year survival rate among patients following surgery (83.7% vs. 15.3% in the non-surgical group; log-rank test <0.0001). In the final multivariable adjusted model, surgery was less likely among patients with liver cirrhosis [OR = 0.03 (95% CI 0.00-0.30)] and with hemodialysis [OR = 0.014 (95% CI 0.00-0.47)].

Conclusion

Patients with left-sided infective endocarditis who do not undergo surgery despite an operative indication are older, have more comorbidities and therefore higher preoperative risk profile and a low 1-year survival. The role of the Endocarditis Team may be particularly important for the decision-making process in this specific group.

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.

Epidemiological Changes and Improvement in Outcomes of Infective Endocarditis in Europe in the Twenty-First Century: An International Collaboration on Endocarditis (ICE) Prospective Cohort Study (2000-2012)

INTRODUCTION

Infective endocarditis (IE) has undergone important changes in its epidemiology worldwide.

METHODS

The study aimed to compare IE epidemiological features and outcomes according to predefined European regions and between two different time periods in the twenty-first century.

RESULTS

IE cases from 13 European countries were included. Two periods were considered: 2000-2006 and 2008-2012. Two European regions were considered, according to the United Nations geoscheme for Europe: Southern (SE) and Northern-Central Europe (NCE). Comparisons were performed between regions and periods. A total of 4195 episodes of IE were included, 2113 from SE and 2082 from NCE; 2787 cases were included between 2000 and 2006 and 1408 between 2008 and 2012. Median (IQR) age was 63.7 (49-74) years and 69.4% were males. Native valve IE (NVE), prosthetic valve IE (PVE), and device-related IE were diagnosed in 68.3%, 23.9%, and 7.8% of cases, respectively; 52% underwent surgery and 19.3% died during hospitalization. NVE was more prevalent in NCE, whereas device-related IE was more frequent in SE. Higher age, acute presentation, hemodialysis, cancer, and diabetes mellitus all were more prevalent in the second period. NVE decreased and PVE and device-related IE both increased in the second period. Surgical treatment also increased from 48.7% to 58.4% (p < 0.01). In-hospital and 6-month mortality rates were comparable between regions and significantly decreased in the second period.

CONCLUSIONS

Despite an increased complexity of IE cases, prognosis improved in recent years with a significant decrease in 6-month mortality. Outcome did not differ according to the European region (SE versus NCE).

Escalation of antimicrobial resistance among MRSA part 2: focus on infections and treatment

INTRODUCTION

MRSA is associated with causing a variety of infections including skin and skin structure infections, catheter and device-related (e.g. central venous catheter, prosthetic heart valve) infections, infectious endocarditis, blood stream infections, bone, and joint infections (e.g. osteomyelitis, prosthetic joint, surgical site), central nervous system infections (e.g. meningitis, brain/spinal cord abscess, ventriculitis, hydrocephalus), respiratory tract infections (e.g. hospital-acquired pneumonia, ventilator-associated pneumonia), urinary tract infections, and gastrointestinal infections. The emergence and spread of multidrug resistant (MDR) MRSA clones has limited therapeutic options. Older agents such as vancomycin, linezolid and daptomycin and a variety of newer MRSA antimicrobials and combination therapy are available to treat serious MRSA infections.

AREAS COVERED

The authors discuss infections caused by MRSA as well as common older and newer antimicrobials and combination therapy for MRSA infections. A literature search of MRSA was performed via PubMed (up to September 2022), using the keywords: antimicrobial resistance; β-lactams; multidrug resistance, Staphylococcus aureus, vancomycin; glycolipopeptides.

EXPERT OPINION

Innovation, discovery, and development of new and novel classes of antimicrobial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection-control measures to minimize the spread of MRSA.

Infective Endocarditis After Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review

Infective endocarditis (IE) is a rare but serious complication following transcatheter aortic valve replacement (TAVR). Despite substantial improvements in the TAVR procedure (less invasive) and its expansion to younger and healthier patients, the incidence of IE after TAVR remains stable, with incidence rates similar to those reported after surgical aortic valve replacement. Although IE after TAVR is recognized as a subtype of prosthetic valve endocarditis, this condition represents a particularly challenging scenario given its unique clinical and microbiological profile, the high incidence of IE-related complications, the uncertain role of cardiac surgery, and the dismal prognosis in most patients with TAVR-IE. The number of TAVR procedures is expected to grow exponentially in the coming years, increasing the number of patients at risk of developing this life-threatening complication. Therefore, a detailed understanding of this disease and its complications will be essential to improve clinical outcomes.

Long-Term Results of Patch Repair in Destructive Valve Endocarditis

OBJECTIVES

Treatment of destructive endocarditis with abscess formation is a surgical challenge and associated with significant morbidity and mortality. A root replacement is often performed in case of an annular abscess. This retrospective study was designed to assess the long-term outcome of extensive debridement and patch reconstruction as an alternative approach.

METHODS

Between November 2007 and November 2016, a selected group of 79 patients (29.6% of all surgical endocarditis cases) with native valve endocarditis (NVE, 53.2%) or prosthetic valve endocarditis (PVE, 46.8%) valve endocarditis underwent surgical therapy with extensive annular debridement and patch reconstruction. Their postoperative course, freedom from recurrent endocarditis, and survival at 1, 5, and 7 years were evaluated.

RESULTS

About two-thirds of patients were in a stable condition, one-third of patients were in a critical state. The median logistic EuroSCORE I was 17%. Infected tissue was removed, and defect closure was performed, either with autologous pericardium for small defects, or with bovine pericardium for larger defects. Overall, in-hospital mortality was 11.3% (NVE: 9.7%, PVE: 13.2%; p = 0.412). In single valve endocarditis survival at 1, 5, and 7 years was 81, 72, 72%, respectively for NVE, and 80, 57, 57%, respectively for PVE (p = 0.589), whereas in multiple valve endocarditis survival at 1, 5, and 7 years was 82, 82, 82% for NVE, and 61, 61, and 31%, respectively for PVE (p = 0.132). Confirmed late reinfection was very low.

CONCLUSION

Surgical treatment of destructive endocarditis with abscess formation using patch repair techniques offers acceptable early and long-term results. The relapse rate was low. PVE and involvement of multiple valves were associated with worse outcomes.

Infective endocarditis in developing countries: An update

Introduction

Despite advances in diagnostic and treatment, morbidity and mortality due to infective endocarditis (IE) has not decreased. There is a discrepancy in epidemiology of IE between developed and developing countries. Over the last years, increased early detection and consequently prevalence of rheumatic heart disease (RHD) and congenital heart disease (CHD) which are considered predisposing conditions for IE, is noted. Here, we present a review of literature on IE in developing countries.

Methods

We conducted a systematic literature search of IE studies in developing countries through PubMed and Embase. We have divided the studies into two groups: studies published before 2015 (group 1) and studies ≥ 2015 (group 2). The outcome was defined as a difference in epidemiology, microbiology, treatment, and mortality over time. The Scale for Assessment of Narrative Review Articles guidelines was applied.

Findings

In total, 16 studies were included. The total number of IE cases was 1,098 and 1,505 in groups 1 and 2, respectively. We compared 4/7 cohorts from group 1 (n = 789) with 5/9 cohorts from group 2 (n = 636). Six studies were not included in the comparison because they were interacting between the two cohorts. Males predominated in all studies. Rheumatic heart disease was higher in group 1 than in group 2 (42.3% vs. 30.3%, p < 0.001) while for CHD there was no change (17.6% vs. 16.7%, p = 0.672). Streptococci infections was lower in group 1 than group 2 (26.2% vs. 37.7%, p < 0.001). The proportion of Staphylococcus aureus was 15.3% in group 1 and 23.6% in group 2, p < 0.001. Negative blood culture (NBC) was higher in group 1 than in group 2 (42.2% vs. 34.1%, p = 0.002). Patients in group 1 received more surgery than in group 2 (38.8% vs. 28.8%, p < 0.001). Mortality was similar in the two groups (20.9% vs. 22.3%, p = 0.518).

Conclusion

This review shows a scarcity of studies on IE in developing countries. Rheumatic heart disease and congenital heart disease are common predisposing conditions. Other risk factors are prosthetic valves, degenerative valve disease (DVD), intravenous drug use, and human immunodeficiency virus infection. While the proportion of IE cases caused by Streptococcus and Staphylococcus has increased, the number of NBC and patients getting surgery has decreased. Mortality has not changed over time. Timely diagnosis and management of patients with RHD and CHD and comprehensive management of IE are warranted.

Optimal Timing for Cardiac Surgery in Infective Endocarditis with Neurological Complications: A Narrative Review

In patients with infective endocarditis and neurological complications, the optimal timing for cardiac surgery is unclear due to the varied risk of clinical deterioration when early surgery is performed. The aim of this review is to summarize the best evidence on the optimal timing for cardiac surgery in the presence of each type of neurological complication. An English literature search was carried out from June 2018 through July 2022. The resulting selection, comprising observational studies, clinical trials, systematic reviews and society guidelines, was organized into four sections according to the four groups of neurological complications: ischemic, hemorrhagic, infectious, and asymptomatic complications. Cardiac surgery could be performed without delay in cases of ischemic vascular neurological complication (provided the absence of severe damage, which can be avoided with the performance of mechanical thrombectomy in cases of major stroke), as well as infectious or asymptomatic complications. In the presence of intracranial hemorrhage, a delay of four weeks is recommended for most cases, although recent studies have suggested that performing cardiac surgery within four weeks could be a suitable option for selected cases. The findings of this review are mostly in line with the recommendations of the current European and American infective endocarditis guidelines.

Surgical management and outcomes of endocarditis in adolescents and adults with congenital heart disease

Background

Adolescents and adults with CHD have increased risk for IE because of anatomic anomalies and burden of intracardiac prosthetic material. There are significant challenges in determining primary surgical or medical management along with limited guidelines to determine management.

Methods

A retrospective review was performed at both the University of Colorado Hospital and Children's Hospital Colorado of patients 12 years of age and older with CHD who were treated for IE between 2009 and 2019.

Results

Of 138 cases, the most common CHD lesions were bicuspid aortic valve (30%) and tetralogy of Fallot (14%). Seventy percent of patients had intracardiac prosthetic material. Of the cases where valvular IE was verified, 51% involved prosthetic valves. Surgical management was pursued in 53% of patients with 7% mortality; 11% of patients did not have surgical management due to elevated perioperative risk with 53% mortality; the remaining patients had non-surgical management due to lack of severe features with 0% mortality. Overall mortality during the initial IE treatment course was 9%, with all-cause mortality of 15%. Recurrence occurred in 12% of patients with median follow-up time of 1.68 years.

Conclusions

We report a large single-center study of IE in the adolescent and adult CHD population. Mortality and recurrence rates remain high in this population. We propose a preliminary algorithm for determining surgical management for IE, as well as potentials for future innovations.

Infective Endocarditis: Still More Challenges Than Convictions

After fourteen decades of medical and technological evolution, infective endocarditis continues to challenge physicians in its daily diagnosis and management. Its increasing incidence, demographic shifts (affecting older patients), microbiology with higher rates of Staphylococcus infection, still frequent serious complications and substantial mortality make endocarditis a very complex disease. Despite this, innovations in the diagnosis, involving microbiology and imaging, and improvements in intensive care and cardiac surgical techniques, materials and timing can impact the prognosis of this disease. Ongoing challenges persist, including rethinking prophylaxis, improving the diagnosis criteria comprising blood culture-negative endocarditis and prosthetic valve endocarditis, timing of surgical intervention, and whether to perform surgery in the presence of ischemic stroke or in intravenous drug users. A combined strategy on infective endocarditis is crucial, involving advanced clinical decisions and protocols, a multidisciplinary approach, national healthcare organization and health policies to achieve better results for our patients.

Nomogram for Predicting In-hospital Mortality in Infective Endocarditis Based on Early Clinical Features and Treatment Options

Aim

The aim of this study was to develop a nomogram based on early clinical features and treatment options for predicting in-hospital mortality in infective endocarditis (IE).

Methods

We retrospectively analyzed the data of 294 patients diagnosed with IE in our hospital from June 01, 2012 to November 24, 2021, determined independent risk factors for in-hospital mortality by univariate and multivariate logistic regression analysis, and established a Nomogram prediction model based on these factors. Finally, the prediction performance of nomogram is evaluated by C-index, bootstrapped-concordance index, and calibration plots.

Results

Age, abnormal leukocyte count, left-sided IE, right-sided IE, and no surgical treatment were independent risk factors for in-hospital mortality in patients with IE, and we used these independent risk factors to construct a nomogram prediction model to predict in-hospital mortality in IE. The C-index of the model was 0.878 (95% CI: 0.824–0.931), and the internal validation of the model by bootstrap validation method showed a prediction accuracy of 0.852 and a bootstrapped-concordance index of 0.53.

Conclusion

Our nomogram can accurately predict in-hospital mortality in IE patients and can be used for early identification of high-risk IE patients.

Malignancy and Endocarditis: Divulging Into the Intertwined Association

Cancer is an immunosuppressive disorder with characteristic features of unchecked cell growth, invasion, and sometimes thromboembolism leading to multiple systemic sequelae, including infective endocarditis. This article has compiled some of the crucial mechanisms by which infective endocarditis occurs in cancer patients, its risk factors, and the existing treatment interventions. It has focused on the necessity of being aware that these multiple pathogeneses are involved in the development of infective endocarditis (IE) in cancer patients, which would help delineate the risk factors associated with the condition and help physicians screen better for specific red flags. Identifying these risk factors and patient-oriented therapy, targeting the necessary elements such as causative organism, patient immune status, type of cancer, choosing evidence-based treatment modalities, and to improve the outcome of the disease in an already exasperating condition called cancer.

Infective Endocarditis: New Challenges in a Classic Disease

Infective endocarditis is a relatively rare, but deadly infection, with an overall mortality of around 20% in most series. Clinical manifestations have evolved in response to significant epidemiological shifts in industrialized nations, with a move toward a nosocomial or health-care-related pattern, in older patients, with more episodes associated with prostheses and/or intravascular electronic devices and a predominance of staphylococcal and enterococcal etiology.Diagnosis is often challenging and is based on the conjunction of clinical, microbiological, and imaging information, with notable progress in recent years in the accuracy of echocardiographic data, coupled with the recent emergence of other useful imaging techniques such as cardiac computed tomography (CT) and nuclear medicine tools, particularly ¹⁸F-fluorodeoxyglucose positron emission/CT.The choice of an appropriate treatment for each specific case is complex, both in terms of the selection of the appropriate agent and doses and durations of therapy as well as the possibility of using combined bactericidal antibiotic regimens in the initial phase and finalizing treatment at home in patients with good evolution with outpatient oral or parenteral antimicrobial therapies programs. A relevant proportion of patients will also require valve surgery during the active phase of treatment, the timing of which is extremely difficult to define. For all the above, the management of infective endocarditis requires a close collaboration of multidisciplinary endocarditis teams.

Impact of an In-Hospital Endocarditis Team and a State-Wide Endocarditis Network on Perioperative Outcomes

Background: Infective endocarditis (IE) requires multidisciplinary management. We established an endocarditis team within our hospital in 2011 and a state-wide endocarditis network with referring hospitals in 2015. We aimed to investigate their impact on perioperative outcomes. Methods: We retrospectively analyzed data from patients operated on for IE in our center between 01/2007 and 03/2018. To investigate the impact of the endocarditis network on referral latency and pre-operative complications we divided patients into two eras: before (n = 409) and after (n = 221) 01/2015. To investigate the impact of the endocarditis team on post-operative outcomes we conducted multivariate binary logistic regression analyses for the whole population. Kaplan–Meier estimates of 5-year survival were reported. Results: In the second era, after establishing the endocarditis network, the median time from symptoms to referral was halved (7 days (interquartile range: 2–19) vs. 15 days (interquartile range: 6–35)), and pre-operative endocarditis-related complications were reduced, i.e., stroke (14% vs. 27%, p < 0.001), heart failure (45% vs. 69%, p < 0.001), cardiac abscesses (24% vs. 34%, p = 0.018), and acute requirement of hemodialysis (8% vs. 14%, p = 0.026). In both eras, a lack of recommendations from the endocarditis team was an independent predictor for in-hospital mortality (adjusted odds ratio: 2.12, 95% CI: 1.27–3.53, p = 0.004) and post-operative stroke (adjusted odds ratio: 2.23, 95% CI: 1.12–4.39, p = 0.02), and was associated with worse 5-year survival (59% vs. 40%, log-rank < 0.001). Conclusion: The establishment of an endocarditis network led to the earlier referral of patients with fewer pre-operative endocarditis-related complications. Adhering to endocarditis team recommendations was an independent predictor for lower post-operative stroke and in-hospital mortality, and was associated with better 5-year survival.

Analysis of sleep characteristics and clinical outcomes of 139 adult patients with infective endocarditis after surgery

BACKGROUND

Little is known about the postoperative sleep quality of infective endocarditis patients during hospitalization and after discharge.

AIM

To investigate the sleep characteristics of infective endocarditis patients and to identify potential risk factors for disturbed sleep quality after surgery.

METHODS

The Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale were used to assess patient sleep quality. Logistic regression was used to explore the potential risk factors.

RESULTS

The study population (n = 139) had an average age of 43.40 ± 14.56 years, and 67.6% were men (n = 94). Disturbed sleep quality was observed in 86 patients (61.9%) during hospitalization and remained in 46 patients (33.1%) at 6 mo after surgery. However, both PSQI and Epworth Sleepiness Scale scores showed significant improvements at 6 mo (P < 0.001 and P = 0.001, respectively). Multivariable logistic regression analysis showed that the potential risk factors were age (odds ratio = 1.125, 95% confidence interval: 1.068-1.186) and PSQI assessed during hospitalization (odds ratio = 1.759, 95% confidence interval: 1.436-2.155). The same analysis in patients with PSQI ≥ 8 during hospitalization suggested that not using sleep medication (odds ratio = 15.893, 95% confidence interval: 2.385-105.889) may be another risk factor.

CONCLUSION

The incidence of disturbed sleep after infective endocarditis surgery is high. However, the situation improves significantly over time. Age and early postoperative high PSQI score are risk factors for disturbed sleep quality at 6 mo after surgery.

Effect of Publicly Reported Aortic Valve Surgery Outcomes on Valve Surgery in Injection Drug- and Non-Injection Drug-Associated Endocarditis

BACKGROUND

Injection drug use-associated infective endocarditis (IDU-IE) is rising and valve surgery is frequently indicated. The effect of initiating public outcomes reporting for aortic valve surgery on rates of valve surgery and in-hospital mortality for endocarditis is not known.

METHODS

For an interrupted time series analysis, we used data from the National Inpatient Sample, a representative sample of United States inpatient hospitalizations, from January 2010 to September 2015. We included individuals aged 18-65 with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of endocarditis. We defined IDU-IE using a validated combination of ICD-9 codes. We used segmented logistic regression to assess for changes in valve replacement and in-hospital mortality rates after the public reporting initiation in January 2013.

RESULTS

We identified 7322 hospitalizations for IDU-IE and 23 997 for non-IDU-IE in the sample, representing 36 452 national IDU-IE admissions and 119 316 non-IDU admissions, respectively. Following the implementation of public reporting in 2013, relative to baseline trends, the odds of valve replacement decreased by 4.0% per quarter (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99), with no difference by IDU status. The odds of an in-patient death decreased by 2.0% per quarter for both IDU-IE and non-IDU-IE cases following reporting (OR 0.98, 95% CI 0.97-0.99).

CONCLUSIONS

Initiating public reporting was associated with a significant decrease in valve surgery for all IE cases, regardless of IDU status, and a reduction in-hospital mortality for patients with IE. Patients with IE may have less access to surgery as a consequence of public reporting. To understand how reduced valve surgery impacts overall mortality, future studies should examine the postdischarge mortality rate.

The 2020 ACC/AHA Guidelines for Management of Patients With Valvular Heart Disease: Highlights and Perioperative Implications

Valvular heart disease contributes to a large burden of morbidity and mortality in the United States. During the last decade there has been a paradigm shift in the management of valve disease, primarily driven by the emergence of novel transcatheter technologies. In this article, the latest update of the American College of Cardiology/American Heart Association valve heart disease guidelines is reviewed.

Insight into the epidemiology of infective endocarditis in Portugal: a contemporary nationwide study from 2010 to 2018

BACKGROUND

Nationwide hospital admissions data series have contributed to a reliable assessment of the changing epidemiology of infective endocarditis, even though conclusions are not uniform. We sought to use a recent populational series to describe the temporal trends on the incidence of infective endocarditis, its clinical characteristics and outcome results, in Portugal.

METHODS

A nationwide retrospective temporal trend study on the incidence and clinical characterization of patients hospitalized with infective endocarditis, between 2010 and 2018.

RESULTS

7574 patients were hospitalized with infective endocarditis from 2010 to 2018 in Portuguese public hospitals. The average length of hospitalization was 29.3 ± 28.7 days, predominantly men (56.9%), and 47.1% had between 60 and 79 years old. The most frequent infectious agents involved were Staphylococcus (16.4%) and Streptococcus (13.6%). During hospitalization, 12.4% of patients underwent heart valve surgery and 20% of the total cohort died. After a 1-year post-discharge follow-up, 13.2% of the total initial cohort had had heart valve surgery and 21.2% in total died. The annual incidence of infective endocarditis was 8.31 per 100,000 habitants, being higher in men (9.96 per 100,000 in males versus 6.82 in females, p < 0.001) and increased with age, peaking at patients 80 years old or older (40.62 per 100,000). In-hospital mortality rate significantly increased during the analyzed period, the strongest independent predictors being ischemic or hemorrhagic stroke, sepsis, and acute renal failure. Younger age and cardiac surgery had a protective effect towards a fatal outcome.

CONCLUSIONS

In Portugal, between 2010 and 2018, the incidence of infective endocarditis presented a general growth trend with a deceleration in the most recent years. Also, a significant rate of in-hospital complications, a mildly lower than expected stable surgical rate and a still high and growing mortality rate were noted.

Evolution of epidemiological characteristics of infective endocarditis in Greece

OBJECTIVE

The clinical profile, management and outcome of infective endocarditis (IE) may be influenced by socioeconomic issues.

METHODS

A nationwide prospective study evaluated IE during the era of deep economic crisis in Greece. Epidemiological data and factors associated with 60-day mortality were analyzed through descriptive statistics, logistic and Cox-regression models.

RESULTS

Among 224 patients (male 72.3%, mean age 62.4 years), Staphylococcus aureus (n = 62; methicillin-resistant S. aureus (MRSA) 33.8%) predominated in the young without impact on mortality (p = 0.593), whilst Enterococci (n = 36) predominated in the elderly. Complications of IE were associated with mortality: heart failure [OR 2.415 (95% CI: 1.159-5.029), p = 0.019], stroke [OR 3.206 (95% CI: 1.190-8.632), p = 0.018] and acute kidney injury [OR 2.283 (95% CI: 1.085-4.805), p = 0.029]. A 60-day survival benefit was solely related to cardiac surgery for IE during hospitalization [HR 0.386 (95% CI: 0.165-0.903), p = 0.028] and compliance with antimicrobial treatment guidelines [HR 0.487 (95% CI: 0.259-0.916), p = 0.026]. Compared with a previous country cohort study, history of rheumatic fever and native valve predisposition had declined, whilst underlying renal disease and right-sided IE had increased (p < 0.0001); HIV infection had emerged (p = 0.002). No difference in rates of surgery and outcome was assessed.

CONCLUSIONS

A country-wide survey of IE highlighted emergence of HIV, right-sided IE and predominance of MRSA in the youth during a severe socioeconomic crisis. Compliance with treatment guidelines promoted survival.

Surgery for infective endocarditis-analysis of factors affecting outcome

Purpose

Despite advances in medical care, infective endocarditis (IE) has high mortality. Surgery for IE though recommended for complications of the disease is still not commonly offered due to conflicting reports in the literature. We reviewed our results of surgery for IE from the last 5 years to assess their outcome.

Methods

A retrospective review from a single center of consecutive patients who underwent surgery for infective endocarditis from September 2014 to December 2019 was done. Data was collected from hospital records and follow-up done up to May 2020. Outcomes evaluated were mortality, follow-up survival, and postoperative complications. Factors affecting mortality and survival were analyzed.

Results

Ninety-seven patients underwent surgery for IE during this period. Seventy-nine had native valve endocarditis (NVE) and 18 had prosthetic valve endocarditis (PVE). The overall postoperative mortality was 13%, with mortality for native valve endocarditis being 11% and that for prosthetic valve endocarditis being 22%, which was not statistically significant. Three-year survival for the overall group was 88.7% with 88.1% for NVE and 91.7% for PVE. Multivariate predictors of operative mortality were a high EuroSCORE II, diabetes mellitus, and the presence of Staphylococcus organism.

Conclusion

Surgery for infective endocarditis has a very acceptable early outcome and intermediate-term survival.

Current Challenges in the Management of Infective Endocarditis

Infective endocarditis is a relatively rare, but deadly cause of sepsis, with an overall mortality ranging from 20 to 25% in most series. Although the classic clinical classification into syndromes of acute or subacute endocarditis have not completely lost their usefulness, current clinical forms have changed according to the profound epidemiological changes observed in developed countries. In this review, we aim to address the changing epidemiology of endocarditis, several recent advances in the understanding of the pathophysiology of endocarditis and endocarditis-triggered sepsis, new useful diagnostic tools as well as current concepts in the medical and surgical management of this disease. Given its complexity, the management of infective endocarditis requires the close collaboration of multidisciplinary endocarditis teams that must decide on the diagnostic approach; the appropriate initial treatment in the critical phase; the detection of patients needing surgery and the timing of this intervention; and finally the accurate selection of patients for out-of-hospital treatment, either at home hospitalization or with oral antibiotic treatment.

Infective Endocarditis Due to Corynebacterium Species: Clinical Features and Antibiotic Resistance

Background

Corynebacterium species are often dismissed as contaminants in blood cultures, but they can also cause infective endocarditis (IE), which is a severe condition. Antibiotic resistance of corynebacteria is increasing making treatment challenging. Reports on IE caused by Corynebacterium species are scarce and more knowledge is needed.

Methods

Cases of IE caused by Corynebacterium species were identified through the Swedish Registry of Infective Endocarditis. Isolates were collected for species redetermination by matrix-assisted laser desorption ionization-time of flight and for antibiotic susceptibility testing using Etests.

Results

Thirty episodes of IE due to Corynebacterium species were identified between 2008 and 2017. The median age of patients was 71 years (interquartile range, 60–76) and 77% were male. Corynebacterium striatum (n = 11) was the most common IE causing pathogen followed by Corynebacterium jeikeium (n = 5). Surgery was performed in 50% and in-hospital mortality rate was 13%. Patients with IE caused by Corynebacterium species were significantly more likely to have prosthetic valve endocarditis (70%), compared with patients with IE due to Staphylococcus aureus or non-beta-hemolytic streptococci (14% and 26%, respectively) (P < .0001). Vancomycin was active towards all Corynebacterium isolates, whereas resistance towards penicillin G was common.

Conclusions

Corynebacterium species cause IE, where prosthetic valves are mainly affected and surgery is often performed. Corynebacterium striatum is an important causative agent of IE within the genus. Antibiotic resistance of corynebacteria is relatively common but resistance towards vancomycin could not be detected in vitro.

Impact of surgical timing on survival in patients with infective endocarditis: a time-dependent analysis

The purpose of this study was to evaluate the impact of surgical timing on survival in patients with left-sided infective endocarditis (IE). This was a retrospective study including 313 patients with left-sided IE between 2009 and 2017. Surgery was defined as urgent (US) or early (ES) if performed within 7 or 28 days, respectively. A multivariable Cox regression analysis including US and ES as time-dependent variables was performed to assess the impact on 1-year mortality. ES was associated with a better survival (aHR 0.349, 95% CI 0.135-0.902), as US (aHR 0.262, 95% CI 0.075-0.915). ES and US were associated with a better prognosis in patients with left-sided IE.

A narrative review of early surgery versus conventional treatment for infective endocarditis: do we have an answer?

The most appropriate strategy and timing for surgery in infective endocarditis (IE) remains an argument of debate. Despite some authors promote the adoption of an early surgical approach (within 48 hours) to limit mortality and complications, no robust randomized trials are available on this argument and the evidence on this subject remain at the "expert opinion" level. Additionally, the different messages promulgated by the American and European guidelines contributed to fuel confusion regarding the relative priority of the surgical over medical therapy in IE. The European Society of Cardiology (ESC) guidelines individuates three level of urgency: emergency surgery, to be performed within 24 hours; urgent surgery, recommended within a few days; elective surgery to be performed after 1-2 weeks of antibiotic therapy. Urgent surgery is recommended for most cases of IE. In the American Heart Association (AHA)'s guidelines define early surgery as "during the initial hospitalization and before completion of a full course of antibiotics." Some of the available evidences showed that are no proven benefits in delaying surgery if a definite diagnosis of IE has been established. However, this argument is controversial across the literature and several factors including the center specific experience can play a role in decision-making. In this review the latest evidences on IE clinical and surgical characteristics along with the current studies on the adoption of an early surgical approach are analyzed to clarify whether enough evidence is available to inform an update of the guidelines.

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.

CHA2DS2-VASc Is Associated With In-Hospital Mortality in Patients With Infective Endocarditis: A Cross-Sectional Cohort Study

Background and objective The CHA2DS2-VASc score is a stroke risk stratification tool that is used in patients with atrial fibrillation (AF). Most of its clinical variables have been associated with poor outcomes in patients with infective endocarditis (IE). In this study, we aimed to determine its utility in predicting outcomes in IE patients. Methods We included 35,570 patients with IE from the National Inpatient Sample (NIS), 2009-2012. The CHA2DS2-VASc score was calculated for each patient. Hierarchical logistic regression was used to estimate the adjusted odds ratio for in-hospital mortality for CHA2DS2-VASc scores from 1 to 9, using a score of 0 as the reference score. All clinical characteristics were defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Results The mean age of the sample was 57.81 ±14 years. Higher CHA2DS2-VASc scores were associated with increased mortality, and the scores among the sample ranged from 0 for 8.1% to 8 for 21.7%. In the hierarchical logistic regression, after adjusting for age, sex, and relevant comorbidities, as the score increased, so did the odds for overall mortality. Conclusion In patients with IE, the CHA2DS2-VASc score may serve as a risk assessment tool with which to predict outcomes. Further studies are needed to replicate these findings.

In-hospital outcomes and prevalence of comorbidities in patients with infective endocarditis with and without heart blocks: Insight from the National Inpatient Sample

Infective endocarditis (IE) complicated by heart block can have adverse outcomes and usually requires immediate surgical and cardiac interventions. Data on outcomes and trends in patients with IE with concurrent heart block are lacking. Patients with a primary diagnosis of IE with or without heart block were identified by querying the Healthcare Cost and Utilization Project database, specifically the National Inpatient Sample for the years 2013 and 2014, based on International Classification of Diseases Clinical Modification Ninth Revision codes. During 2013 and 2014, a total of 18,733 patients were admitted with a primary diagnosis of IE, including 867 with concurrent heart blocks. Increased in-hospital mortality (13% vs 10.3%), length of stay (19 vs 14 days), and cost of care ($282,573 vs $223,559) were found for patients with IE complicated by heart block. Additionally, these patients were more likely to develop cardiogenic shock (8.9% vs 3.2%), acute kidney injury (40.1% vs 32.6%), and hematologic complications (19.3% vs 15.2%), and require placement of a pacemaker (30.6% vs 0.9%). IE and concurrent heart block resulted in increased requirement for aortic (25.7% vs 6.1%) and mitral (17.3% vs 4.2%) valvular replacements. Conclusion was made that IE with concurrent heart block worsens in-hospital mortality, length of stay, and cost for patients. Our analysis demonstrates an increase in cardiac procedures, specifically aortic and/or mitral valve replacements, and Implantable Cardiovascular Defibrillator/Cardiac Resynchronization Therapy/ Permanent Pacemaker (ICD/CRT/PPM) placement in IE with concurrent heart block. A close telemonitoring system and prompt interventions may represent a significant mitigation strategy to avoid the adverse outcomes observed in this study.

[Surgical treatment of infective endocarditis: Surgical indications, complications, intrahospital and long-term mortality]

BACKGROUND

In addition to medical treatment, half of the patients with infective endocarditis (IE) receive surgical treatment. Despite clear recommendations on the indications and the operating delays, the decision remains difficult and must take into consideration several factors.

METHODS

A retrospective study was performed at Foch Hospital. All patients operated for IE between 2005 and 2018 were included. Patient characteristics, indications and operating delays, as well as intrahospital mortality, were noted. Patient follow-up was provided by phone calls.

RESULTS

Fifty-two patients were operated on for IE between 2005 and 2018. The most frequent surgical indications were the presence of a massive symptomatic regurgitation, an uncontrolled infection and large vegetations with embolism. The average operative delay was 13.2 days with 56.5% of patients operated within the first 10 days. The most common postoperative complications were acute kidney injury (AKI) in 57.7% of cases, with 9.6% of dialysis, shock in 50% of cases, rhythm disorders in 40.4% of cases, infectious complications in 19.2% of cases, conductive disorders in 25% of cases, of which 17.3% require a definitive pacemaker implementation. The intrahospital mortality was 7.7% and the average length of hospital stay was 35 days. Survival at one year and 5 years was 95% and 85%, respectively.

CONCLUSION

The indications and the operating delays were conformed to international recommendations. Intrahospital and long-term mortality rate was low.

Infective endocarditis at a tertiary care hospital in South Korea

Objective

The treatment of infective endocarditis (IE) has become more complex with the current myriad healthcare-associated factors and the regional differences in causative organisms. We aimed to investigate the overall trends, microbiological features, and outcomes of IE in South Korea.

Methods

A 12-year retrospective cohort study was performed. Poisson regression was used to estimate the time trends of IE incidence and mortality rate. Risk factors for in-hospital mortality were identified with multivariable logistic regression, and model comparison was performed to evaluate the predictive performance of notable risk factors. Kaplan-Meier survival analysis and Cox regression were performed to assess long-term prognosis.

Results

We included 419 patients with IE, the incidence of which showed an increasing trend (relative risk 1.06, p=0.005), whereas mortality demonstrated a decreasing trend (incidence rate ratio 0.93, p=0.020). The in-hospital mortality rate was 14.6%. On multivariable logistic regression analysis, aortic valve endocarditis (OR 3.18, p=0.001), IE caused by Staphylococcus aureus (OR 2.32, p=0.026), neurological complications (OR 1.98, p=0.031), high Sequential Organ Failure Assessment score (OR 1.22, p=0.023) and high Charlson Comorbidity Index (OR 1.11, p=0.019) were predictors of in-hospital mortality. Surgical intervention for IE was a protective factor against in-hospital mortality (OR 0.25, p<0.001) and was associated with improved long-term prognosis compared with medical treatment only (p<0.001).

Conclusions

The incidence of IE is increasing in South Korea. Although the mortality rate has slightly decreased, it remains high. Surgery has a protective effect with respect to both in-hospital mortality and long-term prognosis in patients with IE.

Endocarditis Complicated by Severe Aortic Insufficiency in a Patient with COVID-19: Diagnostic and Management Implications

A 38-year-old man presented with cough, shortness of breath, and fatigue. He was diagnosed with Coronavirus Disease-2019 (COVID-19) as well as Enterococcus faecalis bacteremia. Imaging revealed a subaortic membrane with aortic valve endocarditis and severe aortic insufficiency. He had successful aortic valve replacement with a mechanical prosthesis and subaortic membrane resection. This case highlights some of the diagnostic and therapeutic challenges presented by COVID-19 pandemic.

Intermittent Recovery of Severe Acute Aortic Regurgitation Arising From Infective Endocarditis

This case reports a 47-year-old male with a history of IV drug abuse, presenting with one week of left lower back pain. During the initial treatment, the patient became hemodynamically unstable, requiring vasopressor support. Transthoracic echocardiography (TTE) revealed a 1 cm x 1 cm aortic valve vegetation with severe aortic regurgitation and potential perforation of the valve leaflet. After hemodynamic stability was achieved, the patient left against medical advice, refusing urgent valvular surgery. Subsequent follow-up unveiled repeated recurrence of symptoms and surgical repair of the aortic valve.

Infective Endocarditis in Persons Who Use Drugs: Epidemiology, Current Management, and Emerging Treatments

Infective endocarditis associated with injection drug use (IDU-IE) is markedly increasing in the United States and Canada. Long-term outcomes are dismal and stem from insufficient substance use disorder treatment. In this review, we summarize the principles of antimicrobial and surgical management for infective endocarditis associated with injection drug use. We discuss approaches to opioid use disorder care and harm reduction in the inpatient setting and review opportunities to address preventable infections among persons injecting drugs. We highlight barriers to implementing optimal treatment and consider novel approaches that may reshape infective endocarditis associated with injection drug use treatment in coming years.