[2015 ESC Guidelines for the management of infective endocarditis. The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC)]

IgA-Dominant Staphylococcus-Associated Glomerulonephritis: An Uncommon Complication of Intravenous Drug Use

A 24-year-old female with a history of intravenous heroin use presented with two weeks of chills, myalgias, and cough and was found to be in acute hypoxemic respiratory failure. Subsequent workup revealed the presence of bilateral septic pulmonary emboli and tricuspid valve endocarditis. Several weeks into her hospitalization, she developed periorbital edema and laboratory testing revealed she had developed acute renal failure and nephrotic range proteinuria. A renal biopsy confirmed the diagnosis of IgA-dominant Staphylococcus-associated glomerulonephritis (IgA-SAGN). Early recognition of this newly recognized variant of glomerulonephritis is paramount, as improper treatment may lead to catastrophic consequences.

Aortic Valve Replacement: A Case of Aortic Valve Insufficiency Secondary to Infective Endocarditis

Acute aortic valve insufficiency (AAVI) is a pathologic medical condition that has a presentation on a spectrum of severity and is attributable to numerous etiologies. Most often, it is caused by infective endocarditis, which depending on the patient's clinical status may require treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This case presents a patient with acute aortic valve insufficiency secondary to infective endocarditis, requiring intervention. Further, it also provides real-time use of the general guidelines used in the determination of SAVR vs. TAVR candidacy. This case will further help providers in the cardiology realm to identify this presentation and increase comfort in referring to existing guidelines, as well as highlight where the current guidelines appear limited.

Early Achromobacter xylosoxidans Endocarditis After the Valvular Mitral Replacement Complicated by an Agranulocytosis on B-lactams: A Case Report

An immunocompetent 82-year-old woman developed endocarditis caused by an atypical organism called Achromobacter xylosoxidans, after a first valvular surgery. The intravenous antibiotic therapy with ceftazidime - 2 g every 8 hours during five weeks - a key part of the treatment, induced agranulocytosis as an adverse event. Cross-reactivity between antibiotics was suspected. Finally, the patient's cure was the result of a coordinated effort between medical and surgical professionals. Postoperative follow-up is six years.

From Pixels to Pathology: Employing Computer Vision to Decode Chest Diseases in Medical Images

Radiology has been a pioneer in the healthcare industry's digital transformation, incorporating digital imaging systems like picture archiving and communication system (PACS) and teleradiology over the past thirty years. This shift has reshaped radiology services, positioning the field at a crucial junction for potential evolution into an integrated diagnostic service through artificial intelligence and machine learning. These technologies offer advanced tools for radiology's transformation. The radiology community has advanced computer-aided diagnosis (CAD) tools using machine learning techniques, notably deep learning convolutional neural networks (CNNs), for medical image pattern recognition. However, the integration of CAD tools into clinical practice has been hindered by challenges in workflow integration, unclear business models, and limited clinical benefits, despite development dating back to the 1990s. This comprehensive review focuses on detecting chest-related diseases through techniques like chest X-rays (CXRs), magnetic resonance imaging (MRI), nuclear medicine, and computed tomography (CT) scans. It examines the utilization of computer-aided programs by researchers for disease detection, addressing key areas: the role of computer-aided programs in disease detection advancement, recent developments in MRI, CXR, radioactive tracers, and CT scans for chest disease identification, research gaps for more effective development, and the incorporation of machine learning programs into diagnostic tools.

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

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

EACVI survey on the evaluation of infective endocarditis

Aims

To evaluate the diagnosis and imaging of patients with suspected endocarditis and the management in routine clinical practice across Europe, the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities and multidisciplinary team was explored.

Methods and results

A total of 100 European Echocardiography Laboratories from 29 different countries responded to the survey, which consisted of 20 questions. For most of the use of echocardiography and advanced imaging, answers from the centres were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, two-thirds of centres report the use of a specific endocarditis team for decision-making. Echocardiography plays a key role in the diagnosis and management of endocarditis. Nuclear imaging modalities are broadly available among the centres and are mainly used in prosthetic valve endocarditis and cardiac device-related infective endocarditis. Computed tomography (CT) is widely available and used to assess for structural valve abnormalities, neurological complications, and to preoperative assessment of the coronary arteries. Most institutions provide structured patients follow-up following hospital discharge.

Conclusion

In Europe, a relatively homogenous adherence to current recommendation was observed for most diagnostic and management including the follow-up of patients with endocarditis. Decision-making is most commonly performed by a multidisciplinary team. Echocardiography remains the first line and central imaging modality for patient diagnosis and assessment, but 60% of centres also commonly use CT, whilst positron emission tomography imaging is used in patients with prosthetic valve endocarditis or device infection.

Preoperative stroke before cardiac surgery does not increase risk of postoperative stroke

The optimal time when surgery can be safely performed after stroke is unknown. The purpose of this study was to investigate how cardiac surgery timing after stroke impacts postoperative outcomes between 2011–2017 were reviewed. Variables were extracted from the institutional Society of Thoracic Surgeons database, statewide patient registry, and medical records. Subjects were classified based upon presence of endocarditis and further grouped by timing of preoperative stroke relative to cardiac surgery: Recent (stroke within two weeks before surgery), Intermediate (between two and six weeks before), and Remote (greater than six weeks before). Postoperative outcomes were compared amongst groups. 157 patients were included: 54 in endocarditis and 103 in non-endocarditis, with 47 in Recent, 26 in Intermediate, and 84 in Remote. 30-day mortality and postoperative stroke rate were similar across the three subgroups for both endocarditis and non-endocarditis. Of patients with postoperative stroke, mortality was 30% (95% CI 4.6–66). Timing of cardiac surgery after stroke occurrence does not seem to affect postoperative stroke or mortality. If postoperative stroke does occur, subsequent stroke-related mortality is high.

Serratia marcescens and other non-AACEK GNB endocarditis: A case report and review of literature

BACKGROUND

Non-Aggregatibacter aphrophilus, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp. (non-AACEK) gram-negative bacilli (GNBs) are an infrequent and challenging cause of endocarditis associated previously with mainly intravenous drug use. Currently, this pathology has increasingly become a healthcare-associated issue. Current guidelines do not clearly define the management of non-AACEK GNB endocarditis due to a lack of prospective trials. We review characteristics, outcomes and treatment of non-AACEK GNB endocarditis, in particular Serratia marcescens endocarditis.

CASE SUMMARY

We describe the case report of a 46-year-old man who presented to the emergency department with high-grade fever and a purulent exudate on an intracardiac device site. Serratia marcescens mitral valve endocarditis as a consequence of complicated generator pocket infection was diagnosed. The patient was treated with complete device removal and a long course of broad-spectrum antibiotics for 6 wk after surgery with intravenous piperacillin-tazobactam and ciprofloxacin, which was later switched to oral ciprofloxacin and sulfamethoxazole-trimethoprim. The patient had complete resolution of symptoms and inflammatory parameters at the end of the treatment and at follow-up.

CONCLUSION

Long-term dual-antibiotic therapy containing a beta-lactam is indicated for most non-AACEK GNB endocarditis, whereas valve surgery may not be necessary in all patients.

Current clinical use of intravenous fosfomycin in ICU patients in two European countries

PURPOSE

In Europe, intravenous fosfomycin (IV) is used particularly in difficult-to-treat or complex infections, caused by both Gram-positive and Gram-negative pathogens including multidrug-resistant strains. Here, we investigated the efficacy and safety of intravenous fosfomycin under real-life conditions.

METHODS

Prospective, multi-center, and non-interventional study in patients with bacterial infections from 20 intensive care units (ICU) in Germany and Austria (NCT01173575).

RESULTS

Overall, 209 patients were included (77 females, 132 males, mean age: 59 ± 16 years), 194 of which were treated in intensive care (APACHE II score at the beginning of fosfomycin therapy: 23 ± 8). Main indications (± bacteremia or sepsis) were infections of the CNS (21.5%), community- (CAP) and hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP, 15.3%), bone and joint infections (BJI, 11%), abdominal infections (11%), and bacteremia (10.5%). Most frequently identified pathogens were S. aureus (22.3%), S. epidermidis (14.2%), Enterococcus spp. (10.8%), E. coli (12.3%) and Klebsiella spp. (7.7%). At least one multidrug-resistant (MDR) pathogen was isolated from 51 patients (24.4%). Fosfomycin was administered with an average daily dose of 13.7 ± 3.5 g over 12.4 ± 8.6 days, almost exclusively (99%) in combination with other antibiotics. The overall clinical success was favorable in 81.3% (148/182) of cases, and in 84.8% (39/46) of patients with ≥ 1 MDR pathogen. Noteworthy, 16.3% (34/209) of patients developed at least one, in the majority of cases non-serious, adverse drug reaction during fosfomycin therapy.

CONCLUSION

Our data suggest that IV fosfomycin is an effective and safe combination partner for the treatment of a broad spectrum of severe bacterial infections in critically ill patients.

Tricuspid valve infective endocarditis complicated with multiple lung abscesses and thoracic empyema as different pathogens: a case report

BACKGROUND

Only 4.1% of tricuspid valve IE cases require surgical intervention. The complication after tricuspid valve IE with lung abscess and empyema is rare.

CASE PRESENTATION

We report the case of a 38-year-old male (an intravenous drug abuser) diagnosed with tricuspid valve IE who underwent tricuspid valve replacement. The case was complicated by multiple lung abscesses and thoracic empyema. The pathogens causing the lung abscesses and empyema were Acinetobacter baumannii complex and Candida albicans, which were different from those causing the endocarditis. After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings with only mild blunting of the right costophrenic angle.

CONCLUSION

The pathogen causing the lung abscess is not always compatible with that causing the endocarditis. Thoracoscopic incision of the abscess with 4 to 6 weeks of broad-spectrum antibiotic treatment is effective and safe.

Impact of pre-operative antimicrobial treatment on microbiological findings from endocardial specimens in infective endocarditis

Treatment of infective endocarditis (IE) should be initiated promptly. This might hamper the chances to identify the causative organism in blood cultures. Microbiological sampling of infected valve in patients undergoing surgery might identify the causative organism. The impact of pre-operative antimicrobial treatment on the yield of valve samples is not known. This study evaluated the impact of the duration of the pre-operative antibiotic treatment on valve culture and 16S rRNA PCR findings from resected endocardial samples. Patients meeting the modified Duke criteria of definite or possible IE and undergoing valve surgery due to IE during 2011–2016 were included from Southern Finland. Eighty-seven patients were included. In patients with shorter than 2 weeks of pre-operative antimicrobial treatment, PCR was positive in 91% (n = 42/46) and valve culture in 41% (n = 19/46) of cases. However, in patients who had 2 weeks or longer therapy before operation, PCR was positive in 53% (n = 18/34) and all valve cultures were negative. In 14% of patients, PCR had a diagnostic impact. In blood-culture negative cases (n = 13), PCR could detect the causative organism in ten patients (77%). These included five cases of Bartonella quintana, one Tropheryma whipplei, and one Coxiella burnetii. Long pre-operative antimicrobial treatment was shown to have a negative impact on microbiological tests done on resected endocardial material. After 2 weeks of therapy, all valve cultures were negative, but PCR was positive in half of the cases. PCR aided in diagnostic work-up, especially in blood culture negative cases.

General Concepts in Adult Congenital Heart Disease

Congenital heart disease in adults (adult congenital heart disease) is a growing burden for healthcare systems. While infant mortality due to congenital heart disease in the last four decades decreased by almost 3-fold, adult congenital heart disease prevalence increased by more than 2-fold in United States. Adult congenital heart disease prevalence is expected to increase steadily until 2050 in projections. Adult congenital heart disease is a multifaceted problem with many dimensions. This manuscript aims to provide an overview of the common adult congenital heart diseases and summarize important points in management of these diseases with possible problems and complications that the patients and the physicians face.

Association of Vegetation Size With Embolic Risk in Patients With Infective Endocarditis: A Systematic Review and Meta-analysis

IMPORTANCE

Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies.

OBJECTIVE

To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques.

DATA SOURCES

A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017.

STUDY SELECTION

Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non-English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other's work.

DATA EXTRACTION AND SYNTHESIS

Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I2 statistic.

RESULTS

The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P < .001) and mortality (OR, 1.63; 95% CI, 1.13-2.35; P = .009) compared with those with a vegetation size less than 10 mm.

CONCLUSIONS AND RELEVANCE

In this meta-analysis of 21 studies, patients with vegetation size greater than 10 mm had significantly increased odds of embolism and mortality. Understanding the risk of embolization will allow clinicians to adequately risk stratify patients and will also help facilitate discussions regarding surgery in patients with a vegetation size greater than 10 mm.

Echocardiography in Infective Endocarditis: State of the Art

PURPOSE OF REVIEW

In this review, we examine the central role of echocardiography in the diagnosis, prognosis, and management of infective endocarditis (IE).

RECENT FINDINGS

2D transthoracic echocardiography (TTE) and transesophageal echocardiography TEE have complementary roles and are unequivocally the mainstay of diagnostic imaging in IE. The advent of 3D and multiplanar imaging have greatly enhanced the ability of the imager to evaluate cardiac structure and function. Technologic advances in 3D imaging allow for the reconstruction of realistic anatomic images that in turn have positively impacted IE-related surgical planning and intervention. CT and metabolic imaging appear to be emerging as promising ancillary diagnostic tools that could be deployed in select scenarios to circumvent some of the limitations of echocardiography. Our review summarizes the indispensable and central role of various echocardiographic modalities in the management of infective endocarditis. The complementary role of 2D TTE and TEE are discussed and areas where 3D TEE offers incremental value highlighted. An algorithm summarizing a contemporary approach to the workup of endocarditis is provided and major societal guidelines for timing of surgery are reviewed.

Magnetic Resonance Imaging Susceptibility-Weighted Imaging Lesion and Contrast Enhancement May Represent Infectious Intracranial Aneurysm in Infective Endocarditis

Background: Infectious intracranial aneurysm (IIA) can complicate infective endocarditis (IE). We aimed to describe the magnetic resonance imaging (MRI) characteristics of IIA. Methods: We reviewed IIAs among 116 consecutive patients with active IE by conducting a neurological evaluation at a single tertiary referral center from January 2015 to July 2016. MRIs and digital cerebral angiograms (DSA) were reviewed to identify MRI characteristics of IIAs. MRI susceptibility weighted imaging (SWI) was performed to collect data on cerebral microbleeds (CMBs) and sulcal SWI lesions. Results: Out of 116 persons, 74 (63.8%) underwent DSA. IIAs were identified in 13 (17.6% of DSA, 11.2% of entire cohort) and 10 patients with aneurysms underwent MRI with SWI sequence. Nine (90%) out of 10 persons with IIAs had CMB >5 mm or sulcal lesions in SWI (9 in sulci, 6 in parenchyma, and 5 in both). Five out of 8 persons who underwent MRI brain with contrast had enhancement within the SWI lesions. In a multivariate logistic regression analysis, both sulcal SWI lesions (p < 0.001, OR 69, 95% CI 7.8-610) and contrast enhancement (p = 0.007, OR 16.5, 95% CI 2.3-121) were found to be significant predictors of the presence of IIAs. Conclusions: In the individuals with IE who underwent DSA and MRI, we found that neuroimaging characteristics, such as sulcal SWI lesion with or without contrast enhancement, are associated with the presence of IIA

Case of Acute ST Segment Elevation Myocardial Infarction in Infective Endocarditis-Management with Intra Coronary Stenting

Embolic events from infective endocarditis can cause acute coronary syndrome. Mortality rate is high and optimal management might be different from those chosen in setting of classic atherosclerotic coronary artery disease. We present a case of 56-year-old male who had received 5 weeks of antibiotics for aortic valve endocarditis and developed acute ST segment elevation myocardial infarction in hospital settings. Interestingly, patient had recent left heart catheterization that was normal. This was recognized as embolic event from sterile vegetation. Patient was managed with balloon angioplasty and placement of intracoronary stent. Following re-vascularization, patient chest pain and electrocardiogram normalized and he improved in short term. However due to multiple comorbidities he had to be intubated and placed on dialysis.