Clinical Suspicion Of Infective Endocarditis Research Articles

Is Infectious Endocarditis Evolving into a Time-Dependent Diagnosis in the Contemporary Epidemiological Era? Emphasis on the Role of Echocardiography as a First-Line Diagnostic Approach.

Despite significant advances in understanding and outcomes in various domains of cardiology, the prognosis of infective endocarditis (IE) remains dismal. One of the main reasons may rely on an even more intricate diagnosis since epidemiology has shifted towards an aggressive infection, typically in older patients with the involvement of prosthetic valves and cardiovascular implantable electronic devices with earlier clinical presentation. In this novel setting, it is critical to avoid a delay in diagnosis that may delay subsequent adequate treatment, further complications, and ultimately poor clinical outcomes. Accordingly, based on the available data, we will examine the proper use of first-line echocardiography representing the first-line imaging method in patients with clinical suspicion of IE. We will focus on the following three crucial questions: (1) What is the threshold to start the echocardiographic diagnostic workup in stable patients? (2) Has infective endocarditis become a time-dependent diagnosis, even in stable patients? (3) What is the appropriate use of echocardiography in unstable patients? Finally, we propose a new mindset to improve the echocardiographic diagnostic workflow.

Abstract 15051: A Large Mitral Valve Vegetation in a Patient Presented With Low Back Pain and Lower Limb Weakness- A Success Story of a Multidisciplinary Team

Case presentation: A 58-year-old gentleman presented to A&E with low back pain for a few days and lower limb weakness for 24 hours. His background history was not medically significant. On examination, GCS 14/15, lower limbs power 2/5, and palpable urinary bladder. DRE revealed poor anal tone. MRI spine showed epidural abscess at L3-L4 & L5-S1 level and urgent decompressive spinal surgery was performed. IV antibiotics were started and the patient was admitted to the general HDU for vasopressor support. Since the operation, he developed cold, pale, swollen right leg, with no palpable peripheral arteries. A CT aortogram showed occlusion of the right popliteal artery. Right popliteal artery exploration with anterior and posterior tibial embolectomy and fasciotomies were done. As the patient was slow to wake up post-surgery, he was transferred to ICU. MRI brain showed no pathology. Transthoracic echocardiogram revealed no vegetation. As clinical suspicion of infective endocarditis was high, transoesophageal echocardiogram and real-time 3D analysis was done which showed a large highly mobile echogenic mass attached to the left atrial surface of the anterior mitral leaflet (A1 and A2) causing moderate MR. Urgent surgical mitral valve repair and removal of a 2 cm vegetation were performed. Both the blood culture and the culture of the vegetation tissue confirmed the growth of Staphylococcus aureus (MSSA). After 8 weeks of hospital stay, the patient was discharged home. Discussion: The objective of this case presentation is to reemphasize that infective endocarditis is not a single organ disease and can present to different specialities. Transthoracic echocardiography has reduced sensitivity in the critical care setting. So, there should be a relatively low threshold for transoesophageal echocardiography. Although the mortality rate of infective endocarditis is relatively high in ICU patients, multidisciplinary team management may result in favourable outcomes.

Very early infective endocarditis after transcatheter aortic valve replacement.

Scarce data exist about early infective endocarditis (IE) after trans-catheter aortic valve replacement (TAVR). The objective was to evaluate the characteristics, management, and outcomes of very early (VE) IE (≤ 30days) after TAVR. This multicenter study included a total of 579 patients from the Infectious Endocarditis after TAVR International Registry who had the diagnosis of definite IE following TAVR. Ninety-one patients (15.7%) had VE-IE. Factors associated with VE-IE (vs. delayed IE (D-IE)) were female gender (p = 0.047), the use of self-expanding valves (p < 0.001), stroke (p = 0.019), and sepsis (p < 0.001) after TAVR. Staphylococcus aureus was the main pathogen among VE-IE patients (35.2% vs. 22.7% in the D-IE group, p = 0.012), and 31.2% of Staphylococcus aureus infections in the VE-IE group were methicillin-resistant (vs. 14.3% in the D-IE group, p = 0.001). The second-most common germ was enterococci (34.1% vs. 24.4% in D-IE cases, p = 0.05). VE-IE was associated with very high in-hospital (44%) and 1-year (54%) mortality rates. Acute renal failure following TAVR (p = 0.001) and the presence of a non-enterococci pathogen (p < 0.001) were associated with an increased risk of death. A significant proportion of IE episodes following TAVR occurs within a few weeks following the procedure and are associated with dismal outcomes. Some baseline and TAVR procedural factors were associated with VE-IE, and Staphylococcus aureus and enterococci were the main causative pathogens. These results may help to select the more appropriate antibiotic prophylaxis in TAVR procedures and guide the initial antibiotic therapy in those cases with a clinical suspicion of IE. Very early infective endocarditis after trans-catheter aortic valve replacement. VE-IE indicates very early infective endocarditis (≤30 days post TAVR). D-IE indicates delayed infective endocarditis.

Suggested modification of the recommendations for echocardiography in patients with clinical suspicion of infective endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is often necessary because of its higher sensitivity for IE compared with TTE. Yet, TOE has an increased risk of complications. The European Society of Cardiology (ESC) has established guidelines for the management of IE with recommendations for the use of TOE in patients with clinical suspicion of IE. Purpose This project aims to evaluate the ESC recommendations for the use of TOE in patients with clinical suspicion of IE. The purpose of the study is further to examine whether the ESC recommendations for TOE among patients with clinical suspicion of IE result in an unnecessarily large number of negative TOE examinations. Methods All TOE examinations performed due to referrals of patients with clinical suspicion of IE between 1 May 2019 and 30 April 2020 at a university hospital in our city were analysed. The variables included for analysis were age; sex; cardiac comorbidities; prosthetic valves; blood culture results; results from TTE and TOE; number of TOEs during the inclusion period; Duke criteria. The TOE and TTE results were compared in relation to the ESC guidelines. Results In total 195 TOE examinations from 160 patients were included, of which 61 (31%) TOEs were positive for IE. All examinations were of patients with clinical suspicion of IE, of which 37 (19%) had negative TTE. Of the 37 patients with negative TTE, 13 had prosthetic valve or intracardiac device of which 5 had positive TOE. All the 24 (12%) examinations with negative TTE and no prosthetic valve or intracardiac device had negative TOE. Conclusions The ESC recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients that get referred for TOE with negative results. To avoid this, we propose a modification of the recommendations for TOE in patients with clinical suspicion of IE. Negative TTE examination with good image quality and no indications for TOE according to Fig 1, could result in avoiding unnecessary TOE examinations without jeopardizing the IE diagnosis. Abstract Figure. Fig 1

Usefulness of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Diagnosis of Infective Endocarditis in Patients With Adult Congenital Heart Disease.

Infective endocarditis (IE) in patients with adult congenital heart disease (ACHD) remains a diagnostic challenge due to difficulties in detecting endocardial lesions by echocardiography. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) has shown good diagnostic performance in prosthetic valve IE. This study aimed to assess its additional diagnostic value in ACHD-associated IE and to characterize its advantages.Methods and Results:Overall, 22 patients with ACHD and clinical suspicion of IE were retrospectively studied. 18F-FDG PET/CT was performed in addition to conventional assessment based on the modified Duke criteria. The final IE diagnosis was determined by an expert team during a 3-month clinical course, resulting in 18 patients diagnosed with IE. Seven patients (39%) were diagnosed with definite IE only by initial echocardiography. An 18F-FDG PET/CT assessment revealed endocardial involvement in the other 9 patients, resulting in the diagnosis of definite IE in 16 in total (88%). Right-sided endocardial lesions were more common (n=12, 67%) but rarely identified by echocardiography, whereas 18F-FDG PET/CT revealed right-sided lesions in 9 patients. A negative 18F-FDG PET/CT (n=7, 39%) assessment was associated with a native valve IE (71% vs. 0%). In 4 patients who were identified with not-IE, neither echocardiography nor 18F-FDG PET/CT detected any suspicious cardiac involvement. In the diagnosis of ACHD-associated IE, characterized by right-sided IE, 18F-FDG PET/CT assessment should be useful.

The clinical value of the endocarditis team: insights from before and after guidelines implementation strategy.

To evaluate the impact of a multidisciplinary the "Endocarditis Team" (ET) on the course and outcome of infective endocarditis (IE) patients. A retrospective before-after study, including hospitalized patients with definite IE, managed before (01.2013-12.2015) and after (01.2016-07.2019) the introduction of an ET. The primary outcomes were defined as 30-day and 1-year mortality and the secondary as conservative vs. invasive strategy, the interval from clinical suspicion of IE to the performance of echocardiography, utilization of multimodality evaluation, time to an invasive procedure, and the duration of hospitalization. Study population included 92 pre-ET and 128 post-ET implementation patients. Baseline characteristics were similar. During the post-ET period compared with pre-ET, we found higher rates of abscesses and extra-cardiac emboli (27.8% vs. 16.3%, p = 0.048); and a higher invasive procedures rate, including lead extraction (15.6% vs. 6.5%, p = 0.035) and noncardiac surgeries (14.8% vs. 6.5%, p = 0.05). Patients managed during the post-ET period had reduced short (8.5% vs. 17.4%, p = 0.048) and long-term mortality (Log-rank = 0.001). In multivariate analysis of risk factors for long-term mortality, period (pre- or post-ET) was not found to be significantly associated with the mortality. Establishment of an ET was associated with faster and more intensive evaluation of patients with IE. During the period of an ET activity, mortality rates were reduced compared with the previous period.

Mobile echodensities on intracardiac device leads: Is it always a cause for concern?

Patients with cardiac implantable electronic devices (CIEDs) frequently undergo transthoracic echocardiography (TTE). As a result, incidental mobile echodensities (MEDs) attached to device leads are commonly detected. The aim of this study was to estimate the incidence and clinical outcomes of incidental MEDs on CIED leads. A retrospective analysis performed between 2011 and 2018 identified 3548 TTE studies performed on 1849 patients with CIEDs. MEDs were identified in 30 patients (1.6%) without clinical suspicion of infective endocarditis (IE). Patients with incidental MEDs were apyrexial, and those tested demonstrated low inflammatory markers and negative blood cultures (BC). In this group, the majority (83%) of MEDs were in the right atrium and no MEDs were detected near the tricuspid valve. Transesophageal echocardiography (TEE) did not influence clinical outcomes. No patient required long-term antibiotics or lead extraction and no IE-related deaths were identified from electronic health records during a mean follow-up period of 43 months (1-89). In contrast, nine patients with suspected IE were all pyrexial with elevated inflammatory markers, had positive BC, and had proven IE. In these cases, the majority of MEDs were at the device lead/tricuspid valve interface. MEDs close to the tricuspid valve were strongly associated with IE (P<.0001). The incidence of MEDs on CIED leads detected on routine TTE was 1.6%. Conservative management of asymptomatic patients with normal inflammatory markers and BC without TEE, antibiotics, or lead extraction did not reveal any signal for long-term adverse events within the limitations of the study.

Screening echocardiography for suspicion of infective endocarditis: Are all the requests justified according to the Guidelines of the European Society of Cardiology (ESC)?

Echocardiograms are largely performed for suspicion of infective endocarditis (IE), and usually have a poor diagnosis yield, especially if there is a low clinical probability. The ESC Guidelines of 2009 and 2015 proposed very large criteria that define clinical suspicion of IE and justify an echocardiogram request. We studied if the patients referred for suspicion of IE had clinical criteria who respected the ESC Guidelines for screening echocardiography, and we tried to identify the factors associated with the diagnosis of IE. We retrospectively examined all the transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE), performed for suspicion of IE between January 2017 and December 2017 in the University Hospital of Nîmes, France. Three hundred and fifty patients were referred for a suspicion of IE. Two hundred and eighty three (80,9%) TTEs and 67 (19,1%) TOEs were performed in first intention. A second exam was performed in 99 (28,3%) patients: a TTE for 56 patients and a TOE for 43 patients. For 61 (17,4%) patients, the echocardiogram request was not appropriate according to referral of the ESC Guidelines, with no sufficient clinical criteria that may allow to suspect an IE. None of these 61 patients was diagnosed with an IE. IE was finally diagnosed in 51 (14,6%) patients. The significant independent factors associated with the diagnosis of IE were: positive blood culture (OR = 26,6 IC95% = [3,6–195,9] P = 0,001), embolic phenomena (OR = 2,4 IC95% = [1,3–4,5] P = 0,005), previous valvular heart disease (OR = 2,7 IC95% = [1,1–6,7] P = 0,003) and sepsis in absence of an extra cardiac source of infection (OR = 12,6 IC95% = [4,4–35,9] P < 0,001) (Fig. 1). One fifth of the patients referred for an echocardiogram had no sufficient clinical criteria to suspect an IE according to the referral of the ESC Guidelines, and none of them was diagnosed with an IE. The use of these criteria for screening echocardiography for suspicion of IE may avoid many unnecessary echocardiograms.

Advantages and limitations of 18-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography in the diagnosis of infective endocarditis

IntroductionThe early diagnosis of infective endocarditis (IE) is a medical challenge and a multidisciplinary approach is essential to improve its frequently fatal prognosis. Our goal was to evaluate the usefulness of [18F]2-fluoro-2-deoxy-d-glucose positron emission tomography (18F-FDG PET) in the diagnosis of this disease. Materials and MethodsWe prospectively assessed 43 patients (five female and 38 male) with clinical suspicion of IE between 2014 and 2017. All patients underwent transesophageal echocardiography (TEE) and an 18F-FDG PET scan, and the results were compared. A positive PET finding was defined as increased FDG uptake on cardiac valves or intracardiac devices. ResultsOut of 43 patients with suspected IE, the diagnosis was confirmed in 30 cases (79.7%). 18F-FDG PET was positive in 24 patients, with 19 showing FDG uptake on cardiac valves (two native and 17 prosthetic) and five on cardiac devices, being concordant with echocardiographic findings in 11 cases. 18F-FDG PET sensitivity was 80%, specificity 92%, positive predictive value (PPV) 96% and negative predictive value (NPV) 66%. Echocardiography presented sensitivity, specificity, PPV and NPV of 36%, 84%, 84% and 36%, respectively. Conclusions18F-FDG PET proved to be a sensitive technique with a high diagnostic value in patients with prosthetic valves and intracardiac devices and suspected IE. Its utility decreased dramatically in patients with suspected IE on native valves, in which TEE presented higher sensitivity and thus better diagnostic value.

Native vertebral osteomyelitis in aged patients: distinctive features. An observational cohort study.

To describe the demographic, clinical, and microbiological profile of native vertebral osteomyelitis (NVO) in aged patients as compared to that of younger patients, to identify differences that could motivate changes in clinical management. Retrospective, observational cohort study (1990-2015) including all adult patients with microbiologically confirmed NVO divided into 2 groups: aged (≥ 65years) vs younger (18-64years). 247 patients included, 138 aged and 109 younger. Relative to younger patients, the aged had higher rates of healthcare-related infection (40.6 vs 25.7%, p = 0.014), previous known heart valve disease (29.7 vs 9.2%, p < 0.001), and concomitant infective endocarditis (38.4 vs 20.2%, p = 0.002). The groups showed similar rates of symptomatic spinal cord compression (14.5 vs 11.9%, p = 0.556) and paraspinal abscesses (62.3 vs 68.8%, p = 0.288) at presentation. There was a trend to lower spine surgery rates in the aged (11.6 vs 17.4%, p = 0.192). On univariate analysis, Staphylococcus aureus infection was associated with higher in-hospital mortality in aged (29%, OR 4.3, 95% CI 1.61-11.45). In-hospital mortality was higher among the aged (14.5 vs 6.4%, p = 0.044) as well as relapse rate due to treatment failure (3.4 vs 1%, p = 0.377). The findings underscore the importance of preventing healthcare-related infection and maintaining high clinical suspicion of infective endocarditis in aged NVO patients to implement proper management. S. aureus infection had a poorer prognosis in this population. As compared to younger patients, spinal surgery rates were slightly lower and overall prognosis poorer in the aged, despite similar rates of symptomatic spinal cord compression and abscesses at presentation.

Marseille scoring system for empiric treatment of infective endocarditis.

Despite advances in medical, surgical, and critical care, infective endocarditis (IE) remains associated with considerable morbidity and mortality. We evaluated the performance of the Marseille score, including clinical data and biological tests obtained within 2h, to identify patients at high risk of IE in order to initiate early antimicrobial treatment. This was secondarily confirmed using modified ESC criteria combined with molecular testing and (18)fluorodeoxyglucose-positron emission tomography/computed tomography as diagnostic tools. In a prospective cohort study, we enrolled 484 patients with cardiovascular predisposition and clinical suspicion of IE from 2011 to 2013. The final diagnosis was definite IE in 123 patients and possible IE in 107. Marseille score was calculated adding one point for each present parameter (range 0-9). This score includes clinical, epidemiological (male, fever, splenomegaly, clubbing, vascular disease and stroke) and biological criteria (Leucocytes >10,000/mm3, sedimentation rate (SR) > 50/mm or C reactive protein >10mg/L and hemoglobin <100g/l). A score of 2 or more performed best in predicting IE in patients with predisposing heart lesions. Sensitivity was better on left-side heart lesions (94%) than on right-side heart lesions (85%) (p = 0.04) and better for valvulopathy (94%) than intra cardiac devices (84%) (p = 0.02). The predictive positive value of prosthetic valves was greater than that of native valves (p = 0.02). Using our simple Marseille score combined with our standardized diagnostic procedures would help improve IE management by focusing on early empiric treatment within 2h of admission for patients with cardiac predisposition factors.

European Society of Cardiology-Proposed Diagnostic Echocardiographic Algorithm in Elective Patients with Clinical Suspicion of Infective Endocarditis: Diagnostic Yield and Prognostic Implications in Clinical Practice.

Background:Echocardiography plays a central role in diagnosing infective endocarditis (IE). Accordingly, the European Society of Cardiology (ESC) has proposed a diagnostic echocardiographic algorithm. However, new studies are still needed to evaluate the degree of implementation of these guidelines in clinical practice and their consequences on incidence and prognosis of IE.Aim:This study aims to investigate the diagnostic yield of the ESC proposed echocardiographic algorithm in patients with suspected IE. We also examined the association among IE diagnosis and clinical outcomes.Methods:Retrospective analysis of a series of patients undergoing the ESC algorithm for clinical suspicion of IE at our institution.Results:Between 2009 and 2013, 323 cases were managed by a multidisciplinary team for clinical suspicion of IE. Following ESC algorithm, 26 (8%) patients were diagnosed with IE and 297 (92%) had IE excluded. In 92% of patients with a good-quality negative transthoracic echocardiography (TTE) and low level of clinical suspicion, the first TTE was considered sufficient to rule out IE. During a mean follow-up of 2.3 ± 1.4 years, patients who had a final diagnosis of IE showed similar mortality (P = 0.2) and rates of combined endpoint (all-cause death, stroke/transient ischemic attack, advanced atrioventricular block, and heart failure) compared to patients without echocardiographic diagnosis of IE (P = 0.5). Only 1% of the patients who had IE excluded experienced IE in the following 3 months, none of them in the subgroup of patients, in which a first negative TTE was considered sufficient to rule out IE.Conclusions:In spite of the current ESC recommendation TTE is used as part of a routine fever screen. Consequently, only a minority of patients had a final echocardiographic diagnosis of IE. Although in patients with low clinical suspicion a first negative TTE is sufficient to rule out IE, the incidence of clinical events is similar regardless the final diagnosis of IE.

Is a Negative Transesophageal Echocardiogram Enough to Stop Treatment?

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Infective Endocarditis (IE) is one of the most life threatening diseases. Echocardiography is a key tool used in diagnosing IE. There are times however when clinical suspicion outweighs diagnostic tests. CASE PRESENTATION: 35-year-old female presented with fever, joint pains, vomiting and a rash. Patient's medical history is significant for a bicuspid aortic valve and an ascending aortic aneurysm with a graft repair. Blood pressure was 93/66 and other vitals were within normal limits. Her physical exam was significant for generalized pustules (palms, soles, face), 2x2 cm ulcerated lesion on the tip of the 3rd right digit, and asymmetric joint tenderness. Cardiovascular exam was significant for Grade II Aortic, Crescendo murmur. Initial labs showed white blood cells count of 20.1 K/uL, Creatinine 2.11 mg/dL, CRP 275 mg/L, ESR 67 MM/HR. Blood cultures were positive for Staphylococcus Aureus. A transesophageal echocardiogram (TEE) showed a bicuspid aortic valve, and no evidence of valvular vegetation. Despite the lack of evidence on TEE, patient treated with Nafcillin for 6 weeks. She was discharged and over the next few weeks she followed up with her primary care doctor. A repeat echocardiogram in 6 weeks did not reveal any vegetations. DISCUSSION: TEE is recommended in patients with high clinical suspicion of IE and a negative or nondiagnostic TTE (transthoracic echocardiogram). The sensitivity of TEE for vegetation is approximately 96 percent for native valves and 92 percent for prosthetic valves, and the specificity for both is approximately 90 percent. Therefore the question arises whether we should continue treatment for IE if TEE is negative? As in this case, clinical suspicion of IE may persist after a negative TEE. Potential sources of false-negative TEE studies include vegetation’s that are smaller than the limits of resolution, previous embolization of vegetation, or inadequate views to detect small abscesses. Accurate differentiation between true vegetation’s and other IE-related changes, such as ruptured chordae, is frequently difficult. It is also important to emphasize that there are blind spots with TEE. CONCLUSIONS: When clinical suspicion of IE is high and the TEE results are negative, a repeat TEE study is warranted within 7 to 10 days, which may demonstrate previously undetected vegetations or abscesses. Even if a TEE is negative, treatment is warranted if clinical suspicion is high. Reference #1: Habib G, Lancellotti P, Antunes MJ, et al. 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). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36:3075. Reference #2: Shively BK, Gurule FT, Roldan CA, Leggett JH, Schiller NB. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol. 1991;18:391-397. DISCLOSURE: The following authors have nothing to disclose: Mouzamjha Faroqui, Amal Shariff No Product/Research Disclosure Information

Echocardiography in Diagnosis and Management of Infective Endocarditis

capabilities of echocardiography and its broad use in routine every day clinical practice. In the evaluation of infective endocarditis echocardiography can detect vegetations on heart valves, cuspis rupture or perforation and perivalvular inflammatory process spreading. According to the Duke criteria echocardiographic finding is one of the main criteria for diagnosis of endocarditis. The positive echocardiographic findings include: vegetations, abscess, new onset of artificial valve dehiscence and new onset of valvular regurgitation [2]. We use echocardiography to detect changes of cardiac valves and to evaluate systolic and diastolic heart function. Vegetations can be found on native or artificial valves and on the pacemaker or implantable cardioverterdefibrillator (ICD) leads. Vegetations are detected in 42-86% of patients with IE by applying echocardiography. The comparison of the results between transoesophageal echocardiography (TOE) and transthoracic echocardiography (TTE) in the detection of vegetations shows better sensitivity of TOE (85-90%) than the sensitivity of TTE (60%). Specificity of TTE is 67%, and specificity of TOE is around 91-98%. 3D and 4D TOE have been used more commonly in the diagnostics in the last ten years. The sensitivity of this new methods in diagnosis of infective endocarditis is similar to 2D TOE, while its specificity is much higher (100%). However, sensitivity of TTE is much lower in detecting vegetations in patients with artificial valves, implanted pacemaker or implantable cardioverter-defibrillator. We can use the echocardiography to determine size, echogenity and mobility of vegetation. Based on this indicators it is possible to make a decision about surgical treatment, estimate the risk of embolic event and predict the clinical outcome [3]. The patients with vegetations that larger than 1,0 cm in diameter have significantly higher risk of embolic event (36%) than the patients with vegetations smaller than 1,0 cm (6%). According to the new Guidelines of European Society of Cardiology (ESC) for the management of infective endocarditis, it is important to perform TTE in each patient with suspicion of infective endocarditis. In all patients with artificial heart valve, pacemaker or cardioverter- defibrillator, it is indicated to perform TOE [5-7]. Further more, in cases of negative TTE in patients with high clinical suspicion of endocarditis, it is advisible to perform TOE as well [4]. About 15 % of patients with endocarditis have normal echocardiographic finding. Echocardiography may not detect vegetations in too early stage of disease or in case when vegetation caused an embolic event [8]. In some cases we may not detect vegetations due to significant preexistent lesions on valves, such as mitral valve prolapse, degenerative process or due to acustic shadows and reverberations caused by artificial valves. In case echocardiography assesment was made in very early stages of disease with negative examination but with high clinical suspicion of infective endocarditis, it is indicated to repeat the TTE and/or TOE within 5-7 days. Conclusion Early diagnosis, prompt and efficient therapy and detecting and dealing with the complications are the most important factors in achieving good outcome in endocarditis treatment. Echocardiography has important role in diagnosis of endocarditis, detection of complications, decision making regarding the surgical treatment and patients follow-up with great prognostic significance remarkably contributing to better outcome.

Optimising the use of transoesophageal echocardiography in diagnosing suspected infective endocarditis

Objectives We evaluated the clinical indication and incremental diagnostic yield gained by transoesophageal echocardiography (TOE) performed after transthoracic echocardiography (TTE) in patients with suspected infective endocarditis (IE).Methods and results We retrospectively analysed 60 pairs of TOE and TTE exams for suspected IE, performed between July 2011 and July 2013 in our district general hospital. The TOE results were classifi ed as ‘positive’ or ‘negative’ based on the Duke criteria, while TTEs were classifi ed as ‘no vegetation’, ‘vegetation’, ‘suspected vegetation’ and ‘cannot exclude vegetation’ according to the fi nal reports. Pre-existent valve disease and Greaves clinical criteria (prosthetic valve, IVDU, positive blood cultures, embolic phenomena and central lines) were also recorded.Among 22/60 (36%) patients, there was no additional diagnostic yield from further TOE after TTE. Of these 22 patients, 6 had negative Greaves criteria while 16 were Greaves positive but had no evidence of IE on TTE in the presence of good image quality. TOE had a higher diagnostic yield in the remaining 38 patients especially in the presence of prosthetic valves, calcifi ed aortic valves, myxomatous/prolapsing mitral valves and poor TTE image quality.Conclusions TOE is not required in patients with low clinical suspicion of IE, when TTE images are of good quality, as there is no additional diagnostic yield.TOE has a higher diagnostic yield and remains a useful tool in patients with intermediate to high suspicion of IE in the presence of poor TTE image quality, calcifi ed aortic valve, myxomatous mitral valve and prosthetic valves.

Usefulness of Presepsin (sCD14-ST) in diagnosis of Infective Endocarditis - preliminary results of an observational study / Utilitatea presepsinului (sCD14-ST) în Endocardita Infecțioasă –rezultate preliminare ale unui studiu observațional

Abstract Background: Soluble CD14 subtype (sCD14-ST), also named presepsin, has been proposed as a novel biomarker for the diagnosis of sepsis. We hypothesized that presepsin value might be helpful in the diagnosis of infective endocarditis (IE). Material and methods: In this prospective study a total of 29 patients with clinical suspicion of IE were enrolled. The plasma presepsin samples were collected at the admittance in the same time with blood cultures, CRP (C-reactive protein) and routine blood tests. Data about the antibiotic treatment prior to admittance were recorded. The diagnosis of IE was made using the Duke modified criteria. Receiver operating characteristic (ROC) curves analysis and binary logistic regression were performed using SPSS software, version 18. A p value less than 0.05 is considered statistically significant. Results: Patients were divided in two subgroups: 14 patients with definite IE and 8 with IE - rejected according to the modified Duke criteria. 7 patients with final diagnosis of sepsis were excluded. Presepsin levels in patient with definite IE were significantly higher than in those with rejected IE (p&lt;0.03). The area under the receiver operating characteristic curve (AUC) was 0.781 (95 % confidence interval (CI) 0.590 - 0.973). The threshold value of presepsin in predicting IE was determined to be 345 pg/ml, of which the clinical sensitivity and specificity were 64% and respectively, 88%. The AUC for CRP was 0.656 (95% CI 0.37-0.88). Conclusion: Presepsin might be a useful additional diagnostic marker in patients with suspected IE. These preliminary results needs confirmation by future studies.

New diagnostic pathways urgently needed. Protocol of PET Guidance I pilot study: positron emission tomography in suspected cardiac implantable electronic device-related infection.

Cardiovascular implantable electronic device (CIED) infection is a complication of increasing incidence. We present a protocol of an observational case control clinical trial "Positron Emission Tomography Combined With Computed Tomography (PET CT) in Suspected Cardiac Implantable Electronic Device Infection, a Pilot Study - PET Guidance I" (NCT02196753). The aim of this observational clinical trial is to assess and standardise diagnostic algorithms for CIED infections (lead-dependent infective endocarditis, generator pocket infection, fever of unknown origin) with PET CT in Poland. Study group will consist of 20 patients with initial diagnosis of CIED-related infection paired with a control group of 20 patients with implanted CIEDs, who underwent PET CT due to other non-infectious indications and have no data for infectious process in follow-up. All patients included in the study will undergo standard diagnostic pro-cess. Conventional/standard diagnostic and therapeutic process will consist of: medical interview, physical examination, laboratory tests, blood cultures; imaging studies: echocardiography: transthoracic (TTE), and, if there are no contraindications transoesophageal, computed tomography scan for pulmonary embolism if indicated; if there are abnormalities in other systems, decisions concerning further diagnostics will be made at the physician's discretion. As well as standard diagnostic procedures, patients will undergo whole body PET CT scan to localise infection or inflammation. Diagnosis and therapeutic decision will be obtained from the Study Committee. Follow-up will be held within six months with control visits at three and six months. During each follow-up visit, all patients will undergo laboratory tests, two blood cultures collected 1 h apart, and TTE. In case of actual clinical suspicion of infective endocarditis or local generator pocket infection, patients will be referred for further diagnostics. Endpoints for the results assessment - primary endpoints are to standardise PET CT in the diagnostic process: sensitivity, specificity, positive predictive value, and negative predictive value of the diagnosis made by PET CT; secondary endpoints are: assessment of usefulness of PET CT for detection of remote infective complications (metastatic abscesses, infected pulmonary emboli), incidence of particular localisations of infection, influence of PET CT on therapeutic decision: confirmation or change of decision based on PET CT, safety and complications of diagnostic process of CIED-related infections with PET CT. Evaluation of PET CT use for device-related infections in a case control study may be conclusive and improve diagnostic pathway.

Polymicrobial endocarditis involving Veillonella parvula in an intravenous drug user: case report and literature review of Veillonella endocarditis

Veillonella spp. are strictly anaerobic, Gram-negative cocci able to ferment various substrates (pyruvate and lactate) that usually present as commensals in the oral, gastrointestinal, and female genital tract microflora [1]. This genus has been reported to be pathogenically involved in periodontitis, periodontal abscess, and various acute oral conditions. In addition, Veillonella spp. may be exceptionally involved in severe infections, including meningitis, osteomyelitis, or prosthetic joint infection [2]. Infective endocarditis (IE) constitutes one of the most serious, albeit uncommon, complications of bloodstream infection (BSI) by Veillonella spp. in patients with predisposing conditions such as valvular heart disease or intravenous (IV) drug abuse [3]. Here we describe a case of IE due to V. parvula in an IV drug user (IDU) and review the scarce literature on this entity. A 35-year-old man presented to the Emergency Department (ED) of our hospital with fever, chills, purulent sputum, and pleuritic pain for about 48 h. He was a current smoker (index of 20 pack-years) and acknowledged a history of active IV drug abuse (heroine and cocaine). His temperature was 39 C, blood pressure was 120/70 mmHg, and his respiratory rate was 24 breaths per minute (bpm). Physical examination revealed a poor oral hygiene with periodontal disease, venipuncture marks in the upper extremities, and basal crackles over the right lung, with no audible cardiac murmurs. Laboratory data showed a mild normocytic anemia (hemoglobin 11.3 g/dL) and white cell count (WCC) of 9.8 9 10/L. A chest X-ray was unremarkable. Because of our clinical suspicion of IE, we initiated empiric treatment with IV ceftriaxone, cloxacillin, and gentamicin. A transthoracic echocardiography (TTE) revealed two oscillating masses (1.5 9 0.5 and 1.5 9 0.4 cm, respectively) on the tricuspid valve with mild regurgitation, and a thoracic computed tomography (CT) showed multiple cavitating nodules compatible with pulmonary septic embolisms. Viridans group Streptococcus was identified by the semiautomated WIDER system (Francisco Soria Melguizo S.A., Madrid, Spain) in four out of four aerobic bottles of blood cultures (BCs) taken at admission and processed using the BacT/Alert System (bioMerieux, Marcy l’Etoile, France). The isolate was not identified to species and was sensitive to penicillin, cefotaxime, ceftriaxone, erythromycin, clindamycin, levofloxacin, trimethoprim–sulfamethoxazole, and vancomycin; therefore, treatment with cloxacillin was discontinued. The patient initially became afebrile, but after 14 days of treatment with ceftriaxone and gentamicin persistent daily fever reappeared. Before the results of repeated BCs were available, the patient had left the hospital ward without medical authorization. He returned 3 days later to the ED complaining of fever (38.8 C) and left pleuritic chest pain a few hours after an IV heroin injection. He was hemodynamically stable, and tachypneic (18 bpm), and the abdominal examination was remarkable for the identification of a 2-cm tender hepatomegaly and 4-cm splenomegaly that had not been noted on the previous admission. The WCC M. A. Perez-Jacoiste Asin I. Serrano-Navarro S. Prieto-Rodriguez Department of Internal Medicine, University Hospital ‘‘12 de Octubre’’, Instituto de Investigacion Hospital ‘‘12 de Octubre’’ (i?12), Universidad Complutense, Madrid, Spain

Q Fever Endocarditis in Romania: The First Cases Confirmed by Direct Sequencing

Infective endocarditis (IE) is a serious, life-threatening disease with highly variable clinical signs, making its diagnostic a real challenge. A diagnosis is readily made if blood cultures are positive, but in 2.5 to 31% of all infective endocarditis cases, routine blood cultures are negative. In such situations, alternative diagnostic approaches are necessary. Coxiella burnetii and Bartonella spp. are the etiological agents of blood culture-negative endocarditis (BCNE) most frequently identified by serology. The purpose of this study is to investigate the usefulness of molecular assays, as complementary methods to the conventional serologic methods for the rapid confirmatory diagnostic of Q fever endocarditis in patients with BCNE. Currently, detection of C. burnetii by culture or an antiphase I IgG antibody titers >800 represents a major Duke criterion for defining IE, while a titers of >800 for IgG antibodies to either B. henselae or B. quintana is used for the diagnosis of endocarditis due to Bartonella spp. We used indirect immunofluorescence assays for the detection of IgG titers for C. burnetii, B. henselae and B. quintana in 57 serum samples from patients with clinical suspicion of IE. Thirty three samples originated from BCNE patients, whereas 24 were tested before obtaining the blood cultures results, which finally were positive. The results of serologic testing showed that nine out of 33 BCNE cases exhibited antiphase I C. burnetii IgG antibody titer >800, whereas none has IgG for B. henselae or B. quintana. Subsequently, we used nested-PCR assay for the amplification of C. burnetii DNA in the nine positive serum samples, and we obtained positive PCR results for all analyzed cases. Afterwards we used the DNA sequencing of amplicons for the repetitive element associated to htpAB gene to confirm the results of nested-PCR. The results of sequencing allowed us to confirm that C. burnetii is the causative microorganism responsible for BCNE. In conclusion, the nested PCR amplification followed by direct sequencing is a reliable and accurate method when applied to serum samples, and it may be used as an additional test to the serological methods for the confirmatory diagnosis of BCNE cases determined by C. burnetii.

Procalcitonin in 759 Patients Clinically Suspected of Infective Endocarditis

Background Diagnostic delay contributes to high morbidity and mortality in infective endocarditis. A readily available diagnostic marker of infective endocarditis is desirable. S-procalcitonin has been proposed as a candidate, but data on its yield are conflicting. We tested its diagnostic value in a large population of patients seen in a tertiary center. Methods This prospective study included 759 consecutive patients referred for echocardiographic examination on clinical suspicion of infective endocarditis. Transthoracic echocardiography was followed by immediate transesophageal examination, and a blood sample was obtained for procalcitonin analysis. Infective endocarditis was diagnosed by an interdisciplinary team and confirmed according to the Duke criteria. The team was unaware of the results of procalcitonin analyses. Results Infective endocarditis was present in 147 patients (19%). Procalcitonin was higher in these patients than in those in whom infective endocarditis was rejected (median, 0.21 ng/mL vs. 0.13 ng/mL; P <.0005). Multivariate analysis identified significant independent determinants of high procalcitonin: blood culture with endocarditis-typical microorganisms (odds ratio [OR], 2.81), temperature ≥38°C (OR, 2.61), symptoms ≤5 days (OR, 2.39), immunocompromised status (OR, 1.74), and male gender (OR, 1.61). Tests at various procalcitonin thresholds yielded an acceptable sensitivity of 95% at 0.04 ng/mL, but specificity was only 14%. Only 12% had procalcitonin below this threshold, which might justify postponement of further examinations for infective endocarditis. Conclusions Procalcitonin was significantly higher in patients with infective endocarditis than in patients without infective endocarditis and bacteremia with endocarditis-typical organisms was the strongest independent determinant of high procalcitonin. The clinical importance of this is questionable, because a suitable procalcitonin threshold for diagnosing or excluding infective endocarditis was not established.