Aortic Endocarditis Research Articles

Surgical treatment of aortic root abscess: 10-year single center experience

The issue of optimal surgical scope in patients with aortic root abscess due to infective endocarditis remains open, since there are different strategies and interventional methods. In addition, the guidelines do not give preference to any particular type of surgical intervention and recommend an individual approach to each situation. The study included 25 patients with aortic root abscess due to aortic valve infective endocarditis. The most frequently performed surgical intervention in patients was the Ross procedure (n=12, 48%). Eight (32%) patients of the center underwent aortic homograft root replacement. Combined surgery was performed in 7 (28%) patients as follows: 3 (12%) patients — interventions on the mitral valve (all patients underwent mitral valve repair due to mitral valve involvement in abscess), 3 (12%) — coronary artery bypass grafting, 1 (4%) — ascending aortic replacement due to dilatation. Five- and ten-year survival after surgical treatment of patients with aortic root abscess was 86,9% and 78,6%, respectively. There was no reintervention and recurrence of infective endocarditis in the long-term period.

Surgical treatment of aortic root abscess: 10-year single center experience

The issue of optimal surgical scope in patients with aortic root abscess due to infective endocarditis remains open, since there are different strategies and interventional methods. In addition, the guidelines do not give preference to any particular type of surgical intervention and recommend an individual approach to each situation. The study included 25 patients with aortic root abscess due to aortic valve infective endocarditis. The most frequently performed surgical intervention in patients was the Ross procedure (n=12, 48%). Eight (32%) patients of the center underwent aortic homograft root replacement. Combined surgery was performed in 7 (28%) patients as follows: 3 (12%) patients — interventions on the mitral valve (all patients underwent mitral valve repair due to mitral valve involvement in abscess), 3 (12%) — coronary artery bypass grafting, 1 (4%) — ascending aortic replacement due to dilatation. Five- and ten-year survival after surgical treatment of patients with aortic root abscess was 86,9% and 78,6%, respectively. There was no reintervention and recurrence of infective endocarditis in the long-term period.

MRSA bacteremia and new-onset aortic and mitral regurgitation: a pernicious and tricky association

Methicillin-resistant Staphylococcus Aureus (MRSA) bacteremia is a complex and lethal condition. We reported the clinical case of a 58-year-old woman who developed MRSA bacteremia after a 3-month hospitalization for trauma and sepsis. Delay in diagnosis of aortic and mitral endocarditis in the setting of new-onset regurgitations, as the application of suboptimal therapy with linezolid and vancomycin, led to widespread disease with embolic dissemination and development of septic infarctions. Clinicians must be aware of the necessity to consider as high risk of endocarditis new onset valvular regurgitations and of the evidence about the need for daptomycin in treating high-risk MRSA bacteremia.

Postmortem Evaluation of Cardiac Valvular Disease in Bald Eagles (Haliaeetus leucocephalus) and a Golden Eagle (Aquila chrysaetos).

Limited data are available regarding cardiac diseases in birds of prey despite their prevalence in these avian species. Literature regarding valvular lesions in birds of prey is scarce and includes single reports of left atrioventricular valvular endocarditis in an adult, free-ranging, male bald eagle (Haliaeetus leucocephalus) and aortic valvular endocarditis in an adult, free-ranging, female red-tailed hawk (Buteo jamaicensis). The purpose of this study was to evaluate the prevalence, signalment, gross necropsy findings, and histologic lesions of valvular lesions in eagles. In this retrospective study, necropsy reports for 24 free-ranging and captive eagles were evaluated over a 15-year period (July 3, 2006-February 28, 2021). Six (25%; 95% confidence interval: 8.9-58.9) birds, 5 bald eagles and 1 golden eagle (Aquila chrysaetos), met the inclusion criteria. Five (83.3%) of the 6 birds had valvular degeneration, 2 (33.3%) had endocarditis, and Staphylococcus aureus was cultured from 1 (16.7%) of the endocarditis cases. The 6 eagles with valvular lesions were all captive adults. Four of the birds were female (66.7%), and the aortic and left atrioventricular valves were equally affected. Acute or chronic cerebral infarcts were present in all 6 birds. Valvular cardiac disease should be considered as a differential diagnosis in eagles exhibiting respiratory distress, neurologic signs, syncope, or in cases of sudden death.

The Bacterial Profile of Aortic Infectious Endocards: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective endocarditis is defined as infection of a native or prosthetic heart valve, endocardial surface, or cardiac device. The causes and epidemiology, as well as the microbiology of the disease have evolved over the last few decades with the doubling of the average age of patients and an increased prevalence in patients with indwelling cardiac devices. Patients and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at ERRAZI Hospital-Mohammed VI University Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form. Results: Over the study period, 46 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. Endocarditis on aortic prosthesis was found in 15%. The valves were rheumatic in 85%. The presumed portal of entry was cutaneous in 45%, oral and ENT in 33%, urinary in 15%, and digestive in 7%. In our series, 21 out of 26 patients presented a biological inflammatory syndrome. At least one or more blood cultures were positive in 38% of cases. Coagulase-negative Staphylococcus was the most common germ in aortic infective endocarditis, found in 40% of positive blood cultures. All the patients in our series had received a combination of broad-spectrum intravenous antibiotic therapy, initially probabilistic, taking into consideration the portal of entry. Adapted after antibiogram results. The evolution during the hospitalization, was marked by an improvement of the clinical state in only 12%, a perioperative death in 38%, and a worsening of the clinical state in 50%, with an average duration of hospitalization of 14 days. In our series, 60% of the patients with positive blood cultures died, whereas there was 75% survival in the group with negative blood cultures. Conclusion: Infective endocarditis is a serious disease because of its high morbidity and mortality. Despite improvements in diagnostic testing, antimicrobial therapy, and surgical intervention, changes in the epidemiology of IE, including the increase in healthcare-associated infections and the virulence of staphylococcus aureus as the causative organism, increase the risk of complications and death in the acute phase of IE. Action must be taken to prevent infective endocarditis, especially in this rheumatically endemic area.

Aortic Valve Surgery in Children With Infective Endocarditis

There are limited data on the outcomes of children who undergo surgery for aortic valve infective endocarditis (IE), and the optimal surgical approach remains controversial. This study investigated the long-term outcomes of surgery for aortic valve IE in children, with a particular focus on the Ross procedure.

Echocardiographic Aspect of Infectious Aortic Endocarditis: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective Endocarditis (IE) is a serious disease whose prognosis depends on early management. Aortic localization is characterized by its progression to myocardial failure and the high number of complications motivating early recourse to surgery. The diagnosis of AR is based on microbiological and imaging studies. Echocardiography is the recommended imaging modality to make the diagnosis, assess the impact and guide surgery.
 Materials and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at the ERRAZI-CHU Mohammed VI Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form.
 Results: During the study period, 26 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. A known history of valvular disease was found in 57% of the cases. Among the native valvular diseases, rheumatic origin was found in 85%. The most common valvular lesions were represented by vegetations (88%), which were mobile in 56%, measuring between 10 and 20 mm in half of the cases, their most predominant localization was on the ventricular side with a tilt.IE on severe IAo was found in 90% of cases. The most common associated valvulopathies were MI (53%), RAo (38%) and MR (34%), whose severity was variable. The association of aortic disease with mitral disease was the most frequent association. Echocardiographic complications were presented by fistulas, perforations and peri-aortic abscesses (2 cases each) which were correlated with severe AI. Regarding the impact of the aortic AR on the LV, we noted a marked dilatation in 42% of cases with a preserved ejection fraction in 74%. A quarter of our patients had undergone transesophageal echocardiography in addition to transthoracic echocardiography, with an average time between admission and completion of 3 days. The indication of its realization was posed in front of the doubt of the visualization of an image of vegetations or suspicion of complications not visualized with the TTE. Valvular lesions found on TEE were essentially vegetations in 45% of cases, prolapses in 22% of cases, as well as abscesses, para-prosthetic leaks and prosthesis deinsertion found in 11% of cases.
 Conclusion: Aortic AR remains a frequent pathology in our context. Aortic insufficiency is the most predisposing valvulopathy and the most common sonographic appearance is vegetations. The results of our study have shown that complications of AE occur preferentially in patients with severe aortic insufficiency.

Transcatheter Aortic Valve Replacement for Aortic Valve Infective Endocarditis: A Systematic Review and Call for Action.

We aimed to systematically analyze the literature on the use of transcatheter aortic valve replacement (TAVR) to treat active aortic valve infective endocarditis (AV-IE). Surgery is declined in one-third of patients with IE who meet indications because of prohibitive surgical risk. TAVR might be an alternative for selected patients with AV-IE as a bridge-to-surgery or stand-alone therapy. PubMed/MEDLINE, Embase, and Cochrane databases were searched (2002-2022) for studies on TAVR use in active AV-IE. Of 450 identified reports, six met inclusion criteria (all men, mean age 71 ± 12years, median Society of Thoracic Surgeons (STS) score 27, EuroSCORE 56). All patients were prohibitive surgical risk candidates. Five out of six patients had severe, and one patient had moderate aortic regurgitation on presentation. Five out of six patients had prosthetic valve endocarditis after surgical valve replacement 13years before (median), and one patient had TAVR a year before hospitalization. All patients had cardiogenic shock as the indication for TAVR. Four patients received balloon-expanding, and two patients received self-expanding TAVR after a median of 19(IQR 9-25) days from diagnosis of IE. No death or myocardial infarction occurred, but one patient had a stroke within the first 30days. The median event-free time was 9 (IQR 6-14) months including no death, reinfection, relapse IE, or valve-related rehospitalization. Our review suggests that TAVR can be considered as an adjuvant therapy to medical treatment for selected patients in whom surgery is indicated for treatment of acute heart failure due to aortic valve destruction and incompetence caused by infective endocarditis, but who have a prohibitive surgical risk. Nonetheless, a well-designed prospective registry is urgently needed to investigate the outcomes of TAVR for this off-label indication. No evidence exists for using the TAVR to treat infection-related surgical indications such as uncontrolled infection or control of septic embolization.

Ischemic Stroke with Aortic Infective Endocarditis Complicated by Pulmonary Artery Abscess

The initial lesions of infective endocarditis (IE) are mainly valvular, but sometimes may cause other cardiac or extracardiac complications. Cerebral involvement is the most frequent site of extracardiac complications caused by IE. They might be the mode of revelation in 10 to 20% of patients. These complications increase morbidity and mortality. We report the case of a patient with IE complicated by a fistulised abscess in the pulmonary artery leading to a stroke.

Extensive aortic root endocarditis with extension into the intervalvular fibrous body: an updated report of a mitral valve sparing approach.

Aortic root abscess can spread to include adjacent cardiac structures, including the central or intervalvular fibrous body and mitral valve. After radical debridement, complex surgical correction is needed. We describe the results of our mitral valve sparing approach. Between January 2004 and December 2020, 60 patients underwent operation for infective endocarditis of the aortic root with extension towards the mitral valve at 2 centres in the Netherlands. Early and late clinical and echocardiographic outcomes were studied. Prosthetic valve endocarditis was present in 42 (70%) patients and emergent or salvage surgery was performed in 8 (13%) patients. After radical debridement of all infected tissue, mitral valve repair was feasible in 48 (80%) patients. Early mortality occurred in 11 (18%) patients while mechanical circulatory support was needed in 8 (13%) patients. At 10 years after surgery, the estimated reintervention-free survival rate was 51.9% (95% confidence interval 37.0-66.8%). Eight patients underwent reintervention; this was more common in patients who underwent aortic valve rather than root replacement and in patients in whom mitral valve repair was performed without ring annuloplasty. For 48 patients who underwent mitral valve repair, the estimated freedom from recurrent mitral regurgitation rate was 64.4% (95% confidence interval 40.1-88.7%) at 10 years after surgery. Surgical intervention for extensive infective endocarditis of the aortic root is related to reasonable perioperative morbidity and mortality. Optimal surgical technique is crucial to lower the risk of late reintervention. Mitral valve repair is feasible in the majority of patients with satisfactory durability.

Aortic Valve Surgery in Children With Infective Endocarditis

There is limited data on the outcomes of children who undergo surgery for aortic valve infective endocarditis (IE), and the optimal surgical approach remains controversial. We investigated the long-term outcomes of surgery for aortic valve IE in children, with a particular focus on the Ross procedure. A retrospective review of all children who underwent surgery for aortic valve IE was performed at a single institution. Between 1989 and 2020, 41 children underwent surgery for aortic valve IE, of whom 16 (39.0%) underwent valve repair, 13 (31.7%) underwent the Ross procedure, 9 (21.9%) underwent a homograft root replacement, and 3 (7.3%) underwent a mechanical valve replacement. Median age was 10.1 years (interquartile range, 5.4-14.1). The majority of children (82.9%, 34/41) had underlying congenital heart disease, while 39.0% (16/41) had previous heart surgery. Operative mortality was 0.0% (0/16) for repair, 15.4% (2/13) for the Ross procedure, 33.3% (3/9) for homograft root replacement, and 33.3% (1/3) for mechanical replacement. Survival at 10 years was 87.5% for repair, 74.1% for Ross, and 66.7% for homograft (P > 0.05). Freedom from reoperation at 10 years was 30.8% for repair, 63.0% for Ross, and 26.3% for homograft (P=0.15 for Ross vs repair, P=0.002 for Ross vs homograft). Children undergoing surgery for aortic valve IE have acceptable long-term survival, although the need for long-term reintervention is significant. The Ross procedure appears to be the optimal choice when repair is not feasible.

Aortic root allograft reoperations

ObjectiveTo investigate outcomes after aortic root allograft reoperation, identify risk factors for morbidity and mortality, and describe practice evolution since publication of our 2006 allograft reoperation study. MethodsFrom January 1987 to July 2020, 602 patients underwent 632 allograft-related reoperations at Cleveland Clinic: 144 before 2006 (early era, which suggested radical explant was superior to aortic-valve-replacement-within-allograft [AVR-only]), and 488 from 2006 to present (recent era). Indications for reoperation were structural valve deterioration in 502 (79%), infective endocarditis in 90 (14%), and nonstructural valve deterioration/noninfective endocarditis in 40 (6.3%). Reoperative techniques included radical allograft explant in 372 (59%), AVR-only in 248 (39%), and allograft preservation in 12 (1.9%). Perioperative events and survival were assessed among indications, techniques, and eras. ResultsOperative mortality by indication was 2.2% (n = 11) for structural valve deterioration, 7.8% (n = 7) in those with infective endocarditis, and 7.5% (n = 3) for nonstructural valve deterioration/noninfective endocarditis, and by surgical approach 2.4% (n = 9) after radical explant, 4.0% (n = 10) for AVR-only, and 17% (n = 2) for allograft preservation. Operative adverse events occurred in 4.9% (n = 18) of radical explants and 2.8% (n = 7) of AVR-only procedures (P = .2). Patients undergoing radical explants received larger valves than those undergoing AVR-only (median, 25 vs 23 mm). ConclusionsAortic root allograft reoperations present a technical challenge but can be performed with low mortality and morbidity. Radical explant offers outcomes similar to AVR-only while allowing for implant of larger prostheses. Increasing experience with allograft reoperations has permitted excellent outcomes; thus, risk of reoperation should not dissuade surgeons from using allografts for invasive aortic valve infective endocarditis and other indications.

The effect of adding an open distal anastomosis to proximal aneurysm repairs in bicuspid aortopathy.

To determine the role of adding open distal anastomosis to proximal aortic aneurysm repairs in bicuspid aortic valve (BAV) patients. Retrospective review was performed of 1132 patients at our Aortic Center between 2005 and 2019. Inclusion criteria were all patients diagnosed with a BAV who underwent proximal aortic aneurysm repair with open or clamped distal anastomosis. Exclusion criteria were patients without a BAV, age < 18years, aortic arch diameter ≥ 4.5cm, type A aortic dissection, previous ascending aortic replacement, ruptured aneurysm, and endocarditis. Propensity score matching in a 2:1 ratio (220 clamped: 121 open repairs) on 18 variables was performed. Median follow-up time was 45.6months (range 7.2-143.4months). In the matched groups, no significant differences were observed between the respective open and clamped distal anastomosis groups for Kaplan Meier 10-year survival (86.9% vs. 92.9%; p = 0.05) and landmark survival analysis after 1year (90.6%; vs. 93.3%; p = 0.39). Overall incidence of aortic arch-related reintervention was low (n = 3 total events). In-hospital complications were not significantly different in the open with respect to the clamped repair group, including in-hospital mortality (2.5% vs. 0.5%; p = 0.13) and stroke (0% vs. 0.9%; p = 0.54). In multivariable analysis, open distal anastomosis repair was not associated with long-term mortality (Hazard Ratio (HR) 1.98; p = 0.06). We found no significant inter-group differences in survival, reintervention, or in-hospital complication rates, with low rates of mortality, and aortic arch-related reintervention, suggesting adding open distal anastomosis may not provide benefit in BAV patients undergoing proximal aortic aneurysm repairs.

Pseudoaneurysm of the Aortic Root in the Presence of Aortic Valve Infective Endocarditis

Herein, we present a case with clinical and laboratory manifestations of infectious endocarditis but in echocardiography, the ventricular septal defect and bicuspid aortic valve were detected without any vegetation. However, an aortic root pseudoaneurysm was first suspected in transesophageal echocardiography and then confirmed in computed tomography angiography of the aorta that points to importance of searching infectious endocarditis complications even in absence of vegetation.

Infective endocarditis caused by Klebsiella pneumoniae in a patient with non ST elevation myocardial infarction

A rare clinical case of native aortic valve infective endocarditis (IE) caused by Klebsiella pneumoniae in a 56-year old man without known risk factors predisposing to the development of IE is presented. Diagnosis of IE in this patient was a challenge due to the lack of recent interventions that could be considered as a source of bacteremia, scarce clinical manifestation and absence of typical complications. Aortic valve vegetation was detected by transesophageal echocardiography. K. pneumoniae isolate was susceptible to all antibiotics tested. Antibacterial therapy (cefepime 6 g/day IV for 2 weeks in the hospital followed by ceftriaxone 4 g/day IM and cefixime 400 mg/day PO, a total of 4 weeks as an outpatient) resulted in a complete resolution of IE signs and symptoms, laboratory abnormalities as well as vegetation size decrease. Surgical treatment was not required in this patient.

EUROPEAN NORDIC APROTININ PATIENT REGISTRY (NAPAR) DATA FROM NORDIC COUNTRIES INDICATE HALVED 30-DAY MORTALITY RATE COMPARED WITH EUROSCORE II IN HIGH-RISK HEART SURGERY

<h3>Objective</h3> According to European Medicines Agency (EMA) the on-label indication for aprotinin is for patients undergoing isolated coronary artery bypass graft surgery (iCABG), who are at high risk of major blood loss. The objective of the study was to describe current on- and off-label use of aprotinin and associated safety endpoints, including mortality, in adult patients undergoing high risk cardiac surgery in Nordic countries. <h3>Design and Method</h3> Data were analysed from cardiac surgery centres in Finland, Norway and Sweden that were participating in the European Nordic aprotinin patient registry (NAPaR), which is a non-interventional, post-authorization safety study (PASS) executed at EMA's request. Ethical approval was given by responsible authorities at each Hospital and all patients agreed to partake. The treating doctors determined if patients were to be given aprotinin. <h3>Results</h3> Altogether 489 patients were given aprotinin between 2016 to 2020 and of those 72.8% were male and 9.8% >75 years old. 59 patients (12.1%, on-label) underwent iCABG and 430 (87.9%, off-label) another procedure, including a surgery for aortic dissection (n=81, 18.8%) and endocarditis (n=175, 35.8%). 437 patients (89.4%) were given the full Hammersmith regimen and 37.2% had experienced at least one earlier heart procedure. 14.9% of all patients were on dual antiplatelet treatment, which affected 72.9% of iCABG and 7.4% of non-iCABG patients. Preoperative renal impairment (creatinine clearance < 85 mL/min) affected 50.7% of patients and 51.7% of the procedures were urgent, 17.0% emergent and 4.9% salvage. Mean/median bypass time was 159/148 min (range 25-637 min). 0.6% of patients had anaphylactic reactions associated with aprotinin. Within 24 and 48 hours postoperatively, 2.5% (CI95%:1.1%-3.8%) and 4.9% (3.0%-6.8%) of patients were reoperated for bleeding, respectively. Rate of postoperative thromboembolic events, day 1 rise in creatinine >44 μmol/L and new dialysis for any reason was 4.7% (CI95%: 2.8%-6.6%), 17.0% (CI95%: 13.6%-20.3%) and 14.3% (11.2%-17.4%), respectively. In-hospital mortality and 30-day mortality was 4.9% (CI95%: 2.8%-6.9%) and 6.3% (CI95%: 3.7%-7.8%) in all patients versus mean EuroSCORE II (estimates 30-day mortality) 11.4% (CI95%: 8.4%-14.0%, p<0.01). 30-day mortality in patients undergoing surgery for aortic dissection and endocarditis was 6.2% (CI95%: 0.9%-11.4%) and 6.3% (CI95%: 2.7%-9.9%) versus mean EuroSCORE II 13.4% (CI95%: 6.1%-21.0%, p=0.11) and 14.5% (CI95%: 12.1%-16.8%, p=0.01), respectively. <h3>Conclusions</h3> In patients given aprotinin at high risk of death and bleeding undergoing cardiac surgery, mainly complex procedures, 30-day mortality was significantly lower, with approximately halved mortality rates compared with estimations by EuroSCORE II. NAPaR data from Nordic countries suggest a favourable safety profile of aprotinin in adult cardiac surgery.

POSSIBLE CORONARY SYNDROME IN A CHILD WITH AORTIC ENDOCARDITIS DURING CARDIAC SURGERY.

Infective endocarditis (IE) in children it is serious condition and has a hospital mortality rate 10-20 % with medical treatment. Although, surgical management is the last chance for severely ill patients and has been associated with a mortality rate of 50 %. This is a case report of a child 10 years old with aortic IE who developed coronary syndrome intraoperatively. A 10-year-old boy with history of aortic valve repair 6 years ago was recently diagnosed with aortic endocarditis. He was transferred to the cardiac center for treatment. Clinically, he was unwell, pale and complaining of chest pain days before the surgery. He was admitted with electrocardiography changes, ST depression DI-II, V5 and V6.Echocardiogram revealed a mobile mass on the aortic valve which prolapsed into the left ventricle during diastole causing severe aortic regurgitation. Heparin anti-coagulation was instituted upon arrival. He received meropenem and teicoplanin for 5 days and was transfused before surgery. He underwent urgent aortic replacement due to the mobile mass on the aortic valve, unresolved EKG changes and increasing heart failure. Intraoperatively during repeat sternotomy and lysis of adhesions he developed worsening coronary syndrome (increase of previous ST depression DI-II and more III). Hypotension and bradycardia developed which did not responded to atropine. Pulseless electrical activity ensued, and open cardiac massage and paediatric advance life support was performed for 25 minutes before establishing cardiopulmonary by-pass (CPB). During CPB he developed increasing of metabolic acidosis, lactate and decreased of urine output less than 0.9 ml/kg/h. Aortic valve replacement with 19 mm mechanical valve was done during hypothermia 28 degrees. Following release of the cross-clamp no electrical activity occurred and was connected to the pacemaker VVI for 3 hours and worsening of lactic acidosis (lactate 17),urine output decreasing and creatinine increasing. Disconnection from CPB was done and the patient died. Surgery was performed in a resource restricted low- and middle-income country Figure 1.Mid esophageal AV Long Axis View (ME AV LAX) 110 degrees: significant size mass attached to right size of aortic valve, moving, creating severe insufficiency. Figure 2.Deep Transgastric Long Axis view (Deep TG LAX) 120 degrees, showed opening of aortic valve, thickened and dysplastic. Significant jet from aortic regurgitation with significant size vegetation and showed LV severe dilated with moderate to severe impairment.

Successful Treatment of Aortic Endocarditis by Achromobacter xylosoxidans with Cefiderocol Combination Therapy in a Non-Hodgkin Lymphoma Patient: Case Report and Literature Review.

Achromobacter&amp;nbsp;xylosoxidans is a Gram-negative aerobic opportunistic bacterium, belonging to the order of Burkholderiales, that can cause infections of virtually all body districts in patients with underlying diseases. However, A. xylosoxidans has rarely been associated with infective endocarditis. The treatment of A. xylosoxidans infections is complicated by both intrinsic and acquired resistance. Here we report on a case of aortic endocarditis by A. xylosoxidans in a Non-Hodgkin lymphoma patient treated with a combination of cefiderocol and other antibiotics, and summarize the available literature.

Abstract 14509: A Rare Case of Cardiac Tamponade as an Initial Presentation of Native Aortic Valve Infective Endocarditis

Background: Pericardial involvement is a rare presentation of infectious endocarditis (IE). We present a case of septic cardiac tamponade, paravalvular abscess and fibrinous pericarditis secondary to native aortic valve (AV) IE. Presentation: A 50-year-old gentleman with a history of IV drug use presented with fever, dyspnea and pleuritic chest pain for one week. He was febrile, tachycardic and hypotensive on presentation. Examination revealed a new onset early diastolic murmur. Workup: EKG showed mild diffuse ST segment elevations and PR segment depressions suggestive of pericarditis. Blood cultures grew Serratia marcescens in 6 out of 6 bottles and IV cefepime was initiated. TTE revealed large effusion with right atrium and right ventricle diastolic collapse consistent with tamponade physiology (fig. A, B). A vegetation was seen on the right coronary cusp of AV along with aortic insufficiency and aortic root abscess. TEE confirmed the above findings (fig. C-F) Management: An emergency cardiac surgery was performed for acute aortic regurgitation and cardiac tamponade. Intraoperative findings revealed 600mL of purulent effusion. A large vegetative mass near left-to-right commissure covering an abscess cavity that extended into the aortic wall that destroyed the annulus and extended into the ventricular muscle. AV replacement with 21mm Inspiris pericardial AV and pericardial patching was done. Epicardial tissue as well as AV leaflet cultures revealed moderate to heavy growth of S. marcescens . He was discharged on cefepime for a total duration of 6 weeks. Follow up TTE revealed normal peak and mean transaortic gradients. Conclusion: Cardiac tamponade is a rare but life-threatening complication of IE. Pericardial involvement should prompt us further work up to exclude intra-cardiac abscess which carries poor prognosis due to high complication rates. Hence, early multidisciplinary team response is of paramount importance to reduce in-hospital mortality.

Invasive Coronary Angiography in Patients with Native or Prosthetic Aortic Valve Endocarditis.

Invasive coronary angiography (ICA) is essential to detect significant coronary artery disease (CAD) but is generally not recommended in patients with infective aortic valve endocarditis. This study aimed to evaluate the risks and benefits of preoperative ICA in patients before aortic valve replacement. Between March 2008 and September 2020, 232 patients were surgically treated for infectious endocarditis of the aortic valve. Sixty-seven (29%) of them underwent preoperative diagnostic ICA and were compared with the patients without preoperative ICA. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the ICA data. The intraoperative data and clinical outcomes after ICA and after surgery were evaluated. ICA revealed a CAD in the majority of our patients (n = 36; 54%): One-vessel disease n = 19 (28%), two-vessel disease n = 6 (9%), and three-vessel disease n = 11 (16%). We observed no adverse events following preoperative diagnostic ICA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischemia were detected. During surgical aortic valve replacement, concomitant coronary artery bypass grafting was performed in 20 patients (30%). In patients with preoperative ICA, postoperative in-hospital mortality was significantly lower (n = 8 [12%] vs. n = 30 [18%]; p < 0.001), while the incidence of postoperative bleeding was higher (n = 18 [27%] vs. n = 22 [13%]; p = 0.022). The new-onset stroke incidence was 5% in each group. Taking a multidisciplinary team approach, ICA is safe in selected patients with aortic valve infectious endocarditis with no adverse clinical outcomes, but significant clinical implications.