Symptomatic and Asymptomatic Neurological Complications of Infective Endocarditis: Impact on Surgical Management and Prognosis

[Inflammatory causes of stroke-Diagnostics and treatment]

Inflammatory causes of stroke are frequent and often pose diagnostic and therapeutic challenges due to the scarcity of randomized trials and the absence of clear guideline recommendations for many scenarios. Following the publication of the recommendations of the European Stroke Organization on primary angiitis of the central nervous system (PACNS) last year, the German Neurological Society (DGN) has issued very clear guidelines this year on the diagnostics and treatment of PACNS and updated the recommendations for systemic vasculitides; however, stroke often occurs not only as a result of primary vascular inflammation but also as a complication of another organ infection. Approximately 5% of all patients with sepsis, ca. 20% of patients with bacterial meningitis and up to 40% of patients with bacterial endocarditis suffer from a stroke as a complication. This article summarizes the key characteristics of these inflammatory causes of stroke and particularly focuses on the current recommendations for diagnostic and therapeutic management.

Aortic and Mitral Valve Endocarditis-Simply Left-Sided Endocarditis or Different Entities Requiring Individual Consideration?-Insights from the CAMPAIGN Database

Background: Aortic valve infective endocarditis (AV-IE) and mitral valve infective endocarditis (MV-IE) are often grouped together as one entity: left-sided endocarditis. However, there are significant differences between the valves in terms of anatomy, physiology, pressure, and calcification tendency. This study aimed to compare AV-IE and MV-IE in terms of patient characteristics, pathogen profiles, postoperative outcomes, and predictors of mortality. Methods: We retrospectively analyzed data from 3899 patients operated on for isolated AV-IE or MV-IE in six German cardiac surgery centers between 1994 and 2018. Univariable and multivariable analyses were performed to analyze the risk factors for 30 day and 1 year mortality. A Log-rank test was used to test for differences in long-term mortality. Results: Patients with MV-IE were more likely to be female (41.1% vs. 20.3%.; p < 0.001). Vegetation was detected more frequently in the MV-IE group (66.6% vs. 57.1%; p < 0.001). Accordingly, the rates of cerebral embolic events (25.4% vs. 17.7%; p < 0.001) and stroke (28.2% vs. 19.3%; p < 0.001) were higher in the MV-IE group. Staphylococci had a higher prevalence in the MV-IE group (50.2% vs. 36.4%; p < 0.001). Patients with MV-IE had comparable 30 day mortality (16.7% vs. 14.6%; p = 0.095) but significantly higher 1 year mortality (35.3% vs. 29.0%; p < 0.001) than those with AV-IE. Kaplan-Meier survival analysis showed significantly lower long-term survival in patients with MV-IE (log-rank p < 0.001). Conclusions: Due to the relevant differences between MV-IE and AV-IE, it might be useful to provide individualized, valve-specific guideline recommendations rather than general recommendations for left-sided IE.

Rothia dentocariosa endocarditis with brain abscess and splenic abscess: case report and brief review

Rothia dentocariosa is a conditionally pathogenic bacterium that may cause infective endocarditis (IE) in selected patients and give rise to a variety of clinical complications, albeit it is not a common IE pathogen. We present the case of a patient diagnosed with Rothia dentocariosa-associated IE secondary to influenza B and thrombocytopenic purpura. The blood culture revealed Rochebacterium caries, cardiac ultrasound detected vegetation, while brain and spleen abscesses manifested and progressively deteriorated. Despite a suboptimal response to anti-infective therapy, the patient ultimately underwent aortic valve replacement. Discharge from the hospital was achieved upon control of the brain abscess and spleen abscess.

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.

Embolic Events in Infective Endocarditis: A Comprehensive Review

Infective endocarditis (IE) is a life-threating entity with three main complications: heart failure (HF), uncontrolled infection (UI) and embolic events (EEs). HF and UI are the main indications of cardiac surgery and have been studied thoroughly. On the other hand, much more uncertainty surrounds EEs, which have an abrupt and somewhat unpredictable behaviour. EEs in the setting of IE have unique characteristics that must be explored, such as the potential of hemorrhagic transformation of stroke. Accurately predicting which patients will suffer EEs seems to be pivotal to achieve an optimal management of the disease, but this complex process is still not completely understood. The indication of cardiac surgery in order to prevent EEs in the absence of HF or UI is in question as scientific evidence is controversial and mainly of a retrospective nature. This revision addresses these topics and try to summarize the evidence and recommendations about them.

Brain abscesses in infective endocarditis: contemporary profile and neuroradiological findings

BACKGROUND

Brain abscesses (BA) are severe lesions in the course of infective endocarditis (IE). We compare the bacteriological, clinical data, background, associated lesions, and outcome of IE patients with and without BAs, and assess the MRI characteristics of BAs.

METHODS

Retrospective study of 351 consecutive patients with definite IE (2005-2020) and at least one brain MRI. Patients with and without BAs were compared.

RESULTS

Twenty patients (5.7%) had BA (80% men; median age: 44.9 ± 11.5). They were younger (p = 0.035) and had a higher rate of predisposing factors (previous IE 20% vs 2.2%, p = 0.03), intravenous drug use [25% vs 2.2%; p < 0.0001]), underlying conditions (HIV infection, 20% vs 2.2%, p < 0.0001; alcohol abuse, 20% vs 2.2% p < 0.0001]; liver disease p = 0.04; hemodialysis, p = 0.001; type 2 diabetes, p = 0.001), bacterial meningitis (p = 0.0029), rare species involvement (35% vs 7%, p < 0.0006) and extra-cerebral abscesses (p = 0.0001) compared to patients without BA. Valve vegetations were larger in Group 1 (p = 0.046). Clinical presentation could suggest the diagnosis of BA in only 7/20 (35%) patients. MR identified 58 BAs (mean/patient 2.9; range 2-12): often multiple (80%), bilateral (55%) and ≤ 10 mm (72%). The presence of BA did not modify cardiac surgery indication and timing. Favorable outcome was observed in 85% of patients.

CONCLUSION

Rates of predisposing, underlying conditions, rare IE agents, meningitis and metastatic abscesses are significantly higher in BA-IE patients. As BAs can develop in asymptomatic IE patients, the impact of brain MRI on their management needs thoroughly to be further investigated.

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.

Screening neuroimaging in neurologically asymptomatic patients with infective endocarditis

BACKGROUND AND PURPOSE

Neurological complications from infective endocarditis (IE) are common and often present with minimal clinical symptoms. In this study, we examine whether screening neuroimaging in asymptomatic patients results in increased detection of neurological complications and leads to improved patient outcomes.

METHODS

Using a database of consecutive adults with IE admitted to a single health system from 2015 to 2019, we selected patients who presented without any neurological symptoms and determined whether these patients underwent screening neuroimaging. The presence of septic emboli, territorial infarcts, intracranial hemorrhage, and mycotic aneurysms was recorded. Variables with significant differences in univariable analyses (p < .1) between those with and without screening neuroimaging were entered into regression models with age and sex to determine predictors of neurological complications and favorable discharge outcomes (modified Rankin score ≤2).

RESULTS

A total of 214 patients were included in the study, of which 154 (72%) received screening neuroimaging. Septic emboli were more common in patients who underwent screening imaging (31% vs. 15%, p = 0.02). In the first multivariate analysis, screening neuroimaging was associated with septic emboli (adjusted odds ratio [aOR] = 2.44, 95% confidence interval [CI]: [1.03-5.75], p = 0.04). In the second multivariate analysis, territorial infarcts (aOR = 0.28, 95% CI: [0.11-0.73], p = .01), but not septic emboli (aOR = 0.71, 95% CI: [0.36-1.43], p = 0.34), were associated with a favorable discharge outcome.

CONCLUSIONS

Screening neuroimaging leads to the detection of more septic emboli in IE, but only territorial infarcts (in contrast to septic emboli) correlate with an unfavorable discharge outcome.

Impact of Brain MRI on the Diagnosis of Infective Endocarditis and Treatment Decisions: Systematic Review and Meta-Analysis

BACKGROUND. Despite increasing use of brain MRI to evaluate patients with suspected infective endocarditis, the clinical impact of brain MRI in this setting has not yet been systematically reviewed. OBJECTIVE. The purpose of this study was to evaluate the frequency of brain MRI findings in patients with suspected or confirmed infective endocarditis and to determine the impact of such findings on clinical decisions. EVIDENCE ACQUISITION. A systematic search of the PubMed, Embase, and Cochrane databases was performed from January 1, 1990, to December 31, 2020, to identify original research investigations of brain MRI in patients with suspected or confirmed infective endocarditis. Study quality was assessed with QUADAS-2. Study endpoints included the frequency of brain MRI findings and the frequency of diagnostic modifications, modification of therapeutic plan, and modification of valve surgery plan resulting from MRI findings. Frequencies were pooled by means of the inverse variance method. Subgroup analysis was performed. EVIDENCE SYNTHESIS. A total of 21 studies with 2133 patients were included. Overall study quality was considered moderate. In terms of brain MRI findings, the pooled frequency of acute ischemic lesions was 61.9% (95% CI, 50.7-71.9%); of cerebral microbleeds, 52.9% (95% CI, 41.6-63.9%); hemorrhagic lesions, 24.7% (95% CI, 15.1-37.9%); abscess or meningitis, 9.5% (95% CI, 5.6-15.6%); and intracranial mycotic aneurysm, 6.2% (95% CI, 4.0-9.4%). Subgroup analysis after exclusion of three studies in which neurologic findings were the indication for all brain MRI examinations yielded similar frequencies of these findings. Six studies included results on the impact of brain MRI findings on clinical decisions. The frequencies of diagnostic modifications in two studies were 5.4% and 32.1%. The pooled frequency of therapeutic plan modification in six studies was 12.8% (95% CI, 6.5-23.7%) and of surgical plan modification in five studies was 14.2% (95% CI, 8.2-23.4%). CONCLUSION. In patients with suspected or confirmed infective endocarditis, brain MRI examinations commonly show relevant abnormalities that affect diagnostic and therapeutic clinical decisions. CLINICAL IMPACT. The findings support a potential role for screening brain MRI in the evaluation of patients with suspected or confirmed infective endocarditis, regardless of the presence or absence of neurologic symptoms.

Neurological Complications in Active Left-Sided Infective Endocarditis Requiring Early Surgery

Introduction: To determine whether preoperative symptomatic neurological complication (SNC) predicts a worse prognosis of patients with active left-sided infective endocarditis who required early surgery.

Methods: We conducted a retrospective chart review and analyzed risk factors for SNCs and immediate, medium-term, and long-term mortality in patients with active left-sided infective endocarditis who required early surgery (median follow-up: 70.5 months).

Results: Of 212 included patients, preoperative SNCs occurred in 22.1%. Independent risk factors for preoperative SNC included early hospital admission (<10 days after symptoms onset), duration of antibiotic therapy <7 days, vegetation diameter > 30 mm, preoperative chronic therapy with steroids, and peripheral embolism. A new postoperative SNC occurred in 12.7% of patients. No significant differences related to preoperative or postoperative SNCs were observed in postoperative mortality (29.8% vs. 31.5%) or during follow-up. No significant differences in postoperative mortality were observed between hemorrhagic or ischemic SNCs. There was a non-significant trend to increased mortality in patients who underwent surgery within 7 days of presenting with SNC (55.5%) compared to those who underwent surgery more than 7 days after SNC (33.3%) (P = 0.171). Concomitant risk of mortality or postoperative hemorrhagic transformation increased when surgery is required during the first week after preoperative SNC (77.5% vs. 25%) (P = 0.017).

Conclusions: Patients with active left-sided infective endocarditis who need early hospital admission are at a higher risk of SNC. Mortality is higher in patients who underwent surgery within 7 days of SNC, but mortality of early surgery is acceptable after the first week of preoperative ischemic or hemorrhagic complication. We have not been able to demonstrate that preoperative nor postoperative SNCs predicted a reduced immediate, medium-term, or long-term survival in the population analyzed in this study.

Infective endocarditis with neurological complications: Delaying cardiac surgery is associated with worse outcome

BACKGROUND

Infective endocarditis (IE) is associated with a high mortality rate, related in part to neurological complications. Studies suggest that valvular surgery should be performed early when indicated, but is often delayed by the presence of neurological complications.

AIM

To assess the effect of delaying surgery in patients with IE and neurological complications and to identify factors predictive of death.

METHODS

In a prospective, single-centre study in a referral centre for IE, all patients with IE underwent systematic screening for neurological complications. The primary outcome was 6-month death. In patients presenting with neurological complications, the prognosis according to surgical status was analysed and a Cox regression model used to identify variables predictive of death.

RESULTS

Between April 2014 and January 2018, 351 patients with a definite diagnosis of left-sided IE were included. Ninety-four patients (26.8%) presented with at least one neurological complication. Fifty-nine patients (17.7%) died during 6-month follow-up. Six-month mortality rates did not differ significantly between patients with and without neurological complications (P=0.60). Forty patients had a temporary surgical contraindication because of neurological complications. During the period of surgical contraindication, seven of these patients (17.5%) died, six (15.0%) presented a new embolic event, and 12 (30.0%) presented cardiac or septic deterioration. In multivariable analysis, predictive factors of death in patients presenting with neurological complications were temporary surgical contraindication (hazard ratio 7.36, 95% confidence interval 1.61-33.67; P=0.010) and presence of a mechanical prosthetic valve (hazard ratio 16.40, 95% confidence interval 2.22-121.17; P=0.006).

CONCLUSIONS

Patients with a temporary surgical contraindication due to neurological complications had a higher risk of death and frequent major complications while waiting for surgery. When indicated, the decision to postpone surgery in the early phase should be weighed against the risk of infectious or cardiac deterioration.

Infective endocarditis is associated with worse outcomes in stroke: A Thailand National Database Study

BACKGROUND

There is lack of data on the association between infective endocarditis (IE) and outcomes of mortality and complications in stroke. We aimed to compare characteristics and outcomes of stroke patients with and without IE.

METHODS

We retrospectively examined the above association using data obtained from an insurance database which covers ~75% of the Thai population. All hospitalised strokes between 8 January 2003 and 31 December 2013 were included in the current study. Characteristics and outcomes were compared between stroke patients with or without IE, and then between two main stroke types. Multiple logistic regression models including propensity score-matched analyses were constructed to assess study outcomes controlling for age, sex, stroke type and comorbidities.

RESULTS

A total of 590 115 stroke patients (mean (SD) age = 64.2 ± 13.7 years; ischaemic = 51.7%; haemorrhagic = 32.6%; undetermined = 15.7%) were included, of whom 2129 (0.36%) had stroke associated with IE. After adjustment, we found that IE was significantly associated with the following complications: arrhythmias (adjusted odds ratio (95% CI) 6.94 (6.29-7.66)), sepsis (1.24 (1.01-1.52)), pneumonia (1.34 (1.17-1.53)), respiratory failure (1.43 (1.24-1.66)) and in-hospital mortality (1.29 (1.13-1.47)) (P for all <.001). Patients with haemorrhagic stroke with IE had poorer outcomes for in-hospital mortality and respiratory failure compared with their counterparts with ischaemic stroke. Propensity score-matched analysis showed similar results.

CONCLUSIONS

Our results suggest that stroke patients with IE differ from that of the general stroke population and these patients have worse outcomes. Future studies are needed to determine the best treatment strategies for stroke patients with IE.

Learning From Controversy: Contemporary Surgical Management of Aortic Valve Endocarditis

Aortic valve replacement is the commonest cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies guided by the comprehensive evaluation of the extension of the infection and its microbiological characteristics, clinical profile of the patient, and risk of infection recurrence are currently available. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. However, in cases of complex IE with the involvement of the root or the aortomitral continuity, the use of homograft is suggested according to the surgeon and center experience. Homograft use should be counterbalanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit (mechanical and bioprosthetic) are also potentially suitable alternatives. Further development of preservation techniques enabling longer durability of allogenic substitutes is required. We evaluate the current evidence for the use of valve substitutes in aortic valve endocarditis and propose an evidence-based algorithm to guide the choice of therapy. We performed a systemic review to clarify the contemporary surgical management of aortic valve endocarditis.

Long-term Outcome of Neurological Complications after Infective Endocarditis

Severe neurological complications following infective endocarditis remain a major problem with high mortality rate. The long-term neurological consequences following infective endocarditis remain uncertain. Otherwise, neurosurgeries could be performed after these complications; however, few clinical series have reported the results. Therefore, we utilized a large, nationwide database to unveil the long-term mortality and neurosurgical outcome following infective endocarditis. We included patients with a first-time discharge diagnosis of infective endocarditis between January 2001 and December 2013 during hospitalization. Patients were further divided into subgroups consisting of neurological complications under neurosurgical treatment and complications under non-neurosurgical treatment. Long-term result of symptomatic neurological complications after infective endocarditis and all-cause mortality after different kinds of neurosurgeries were analyzed. There were 16,495 patients with infective endocarditis included in this study. Symptomatic neurological complications occurred in 1,035 (6.27%) patients, of which 279 (26.96%) accepted neurosurgical procedures. Annual incidence of neurological complications gradually increased from 3.6% to 7.4% (P < 0.001). The mortality rate among these patients was higher than that among patients without complications (48.5% vs. 46.1%, P = 0.012, increased from 20% initially to nearly 50% over the 5-year follow-up). However, neurosurgery had no effect on the long-term mortality rate (50.9% vs. 47.6%, P = 0.451). Incidence of neurological complications post-infective endocarditis is increasing, and patients with these complications have higher mortality rates than patients without. Neurosurgery in these populations was not associated with higher long-term mortality. Therefore, it should not be ruled out as an option for those with neurological complications.

Infective endocarditis: innovations in the management of an old disease

The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke-Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke-Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. In the past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures.

[Complications and prognosis of infective endocarditis]

Clinical manifestations of infective endocarditis may involve almost all body organs. They are usually classified as either cardiac or extra-cardiac complications. The first stage of infection is the development of intra-cardiac vegetation, which may further spread with an increase in size and number of vegetations, destructive valve lesions, and perivalvular extension of the infection. These anatomical lesions are responsible for hemodynamic disorders, mostly valvular regurgitation, and often lead to heart failure, which is the most frequent complication of IE. Embolic events may affect various vascular territories, the most frequent sites being brain, spleen and kidney for left-sided IE, and lung for right-sided IE. Cerebral complications may be of ischemic, hemorrhagic and/or infectious origin, are often the revealing symptoms of IE, and are well-recognized factors of poor prognosis. IE remains a dreadful disease with an in hospital mortality of 20%, a 5 year mortality of 40% and a significant morbidity.

[Infective endocarditis in Morocco through the experience of a hospital department]

Infective endocarditis is a grave disease because of a high level of morbidity and mortality. We conducted a retrospective analysis of 100 patients hospitalized for infective endocarditis from January 2009 until December 2015. The mean age was 41 years with a male predominance. Infective endocarditis occurs on a native valve (77 patients), prosthetic valves (12 patients), Pacemaker (7 patients) and congenital heart disease (4 patients). The diagnostic delay was 77 days on average. The fever was present in 85 patients. Blood cultures were negative in 54 patients. Echocardiography allowed visualizing the vegetations in 95 patients. In patients with prosthetics valves, a paraprosthetic regurgitation was diagnosed in 54 % of these patients and vegetation in 18 %. The main complications are heart failure (42), neurological (19), spleen (10) and renal (23) complications. The evolution under medical treatment was marked by the clinical-laboratory improvement in 57 patients, the lack of improvement with persistent fever in 21 patients. The mortality rate of our series is 23 %. Only seven patients underwent urgent surgery for hemodynamic and infectious indications. At the end of this work, it is emphasized that the epidemiological profile of infective endocarditis does not follow the changes of Wold. Its management is difficult in our context (significant diagnostic delay, often negative blood cultures, high level of morbidity, lack of recourse to early surgery). The improvement of this disease consistes of the prevention of acute articular rhumatism and the establishment of an heart team endocarditis to adapt international recommendations to our context.

Possible relationship between antiphospholipid antibodies and embolic events in infective endocarditis

OBJECTIVE

Antiphospholipid (aPL) antibodies may activate platelets and contribute to vegetation growth and embolisation in infective endocarditis (IE). We aimed to determine the value of aPL as predictors of embolic events (EE) in IE.

METHODS

We studied 186 patients with definite IE (Duke-Li criteria, all types of IE) from the Nanc-IE prospective registry (2007-2012) who all had a frozen blood sample and at least one imaging procedure to detect asymptomatic or confirm symptomatic EE. Anticardiolipin (aCL) and anti-β₂-glycoprotein I (β₂GPI) antibodies (IgG and IgM) were assessed after the end of patients' inclusion. The relationship between antibodies and the detection of EE after IE diagnosis were studied with Kaplan-Meier and Cox multivariate analyses.

RESULTS

At least one EE was detected in 118 (63%) patients (52 cerebral, 95 other locations) after IE diagnosis in 80 (time interval between IE and EE diagnosis: 5.9±11.3 days). At least one aPL antibody was found in 31 patients (17%).Detection of EE over time after IE diagnosis was more frequent among patients with anti-β₂GPI IgM (log-rank P=0.0036) and that of cerebral embolisms, among patients with aCL IgM and anti-β₂GPI IgM (log-rank P=0.002 and P<0.0001, respectively).Factors predictive of EE were anti-β₂GPI IgM (HR=3.45 (1.47-8.08), P=0.0045), creatinine (2.74 (1.55-4.84), P=0.0005) and vegetation size (2.41 (1.41-4.12), P=0.0014). Those of cerebral embolism were aCL IgM (2.84 (1.22-6.62), P=0.016) and anti-β₂GPI IgM (4.77 (1.79-12.74), P=0.0018).

CONCLUSION

The presence of aCL and anti-β₂GPI IgM was associated with EE, particularly cerebral ones, and could contribute to assess the embolic risk of IE.

Neurologic Complications of Infective Endocarditis: Recent Findings

PURPOSE OF REVIEW

The purpose of this paper is to provide recent insights in management of neurologic complications of left-sided infective endocarditis (IE).

RECENT FINDINGS

Cerebral lesions observed in IE patients are thought to involve synergistic pathophysiological mechanisms including thromboembolism, sepsis, meningitis, and small-vessel cerebral vasculitis. Brain MRI represents a major tool for the detection of asymptomatic events occurring in the majority of patients. The latter can impact therapeutic decisions and prognosis, especially when cardiac surgery is indicated. In patients presenting with neurologic complications, surgery could be safely performed earlier than previously thought. Symptomatic cerebral ischemic or hemorrhagic events occur in 20-55% of IE patients, whereas asymptomatic events are detected in 60-80% of patients undergoing systematic brain MRI. Management of such patients requires an experienced multidisciplinary team. Recent studies suggest that early cardiac surgery, when indicated, can be performed safely in patients with cerebral ischemic events. Other important issues include the appropriate use of anti-infective and anti-thrombotic agents, and endovascular treatment for mycotic aneurysms. Altered mental status at IE onset, which is associated with brain injury, is a major determinant of short-term outcome.

Extracardiac Imaging of Infective Endocarditis

PURPOSE OF REVIEW

This review analyzes recent studies evaluating the diagnostic and therapeutic impacts of systematic extracardiac imaging techniques in patients with suspected or proven infective endocarditis.

RECENT FINDINGS

Extracardiac imaging techniques are more and more frequently used to establish infective endocarditis (IE) diagnosis in doubtful situations. They also help in evaluating the risk-benefit balance of therapeutic strategies and particularly valvular surgery which is performed in approximately 50% of patients. Latest research underlines the high frequency of asymptomatic lesions found, and a different advantage-disadvantage profile for each of these techniques. Extracardiac imaging techniques are helpful in doubtful situations and may be considered in other situations. Their interest for improving patients' prognosis remains to be established.