Complication Of Infective Endocarditis Research Articles

Staphylococcal endocarditis in a quadricuspid aortic valve following uncomplicated dengue infection: a case report

BackgroundDengue fever is endemic and a leading health problem in Sri Lanka. Increased incidence of concurrent bacteremia in patients with dengue infection is a recognized complication. However, Staphylococcal endocarditis following dengue fever is uncommon. Quadricuspid aortic valve (QAV) is a rare congenital anomaly and few cases of infective endocarditis have been reported in QAV.Case presentationA 32-year-old Sri Lankan male presented to the National Hospital of Sri Lanka with recurrence of fever and acute left hemiplegia following an uncomplicated recovery of dengue fever. He was diagnosed to have Staphylococcal infective endocarditis of quadricuspid aortic valve, with septic emboli to brain and spleen. He was managed with intravenous vancomycin initially, however, due to inadequate response, intravenous linezolid was added. He developed rhabdomyolysis with very high creatine phosphokinase leading to acute kidney injury, which settled with the cessation of linezolid. The patient succumbed to his illness despite aggressive antimicrobial therapy and maximum supportive care while being assessed for aortic valve replacement.ConclusionsThis case illustrates three clinical issues that a clinician should be aware of. Firstly, the possibility of a serious secondary bacterial infection as a cause for recurrence of fever following dengue infection. Secondly, this case highlights the importance of identifying QAV as a cause for complicated infective endocarditis of increased severity. The report also denotes the value of being vigilant of linezolid induced rhabdomyolysis which had a causal relationship with the commencement of the drug and its cessation.

Short-course antibiotic regimen compared to conventional antibiotic treatment for gram-positive cocci infective endocarditis: randomized clinical trial (SATIE)

BackgroundMost serious complications of infective endocarditis (IE) appear in the so-called “critical phase” of the disease, which represents the first days after diagnosis. The majority of patients overcoming the acute phase has a favorable outcome, yet they remain hospitalized for a long period of time mainly to complete antibiotic therapy. The major hypothesis of this trial is that in patients with clinically stable IE and adequate response to antibiotic treatment, without signs of persistent infection, periannular complications or metastatic foci, a shorter antibiotic time period would be as efficient and safe as the classic 4 to 6 weeks antibiotic regimen.MethodsMulticenter, prospective, randomized, controlled open-label, phase IV clinical trial with a non-inferiority design to evaluate the efficacy of a short course (2 weeks) of parenteral antibiotic therapy compared with conventional antibiotic therapy (4–6 weeks).Sample: patients with IE caused by gram-positive cocci, having received at least 10 days of conventional antibiotic treatment, and at least 7 days after surgery when indicated, without clinical, analytical, microbiological or echocardiographic signs of persistent infection. Estimated sample size: 298 patients. Intervention: Control group: standard duration antibiotic therapy, (4 to 6 weeks) according to ESC guidelines recommendations. Experimental group: short-course antibiotic therapy for 2 weeks. The incidence of the primary composite endpoint of all-cause mortality, unplanned cardiac surgery, symptomatic embolisms and relapses within 6 months after the inclusion in the study will be prospectively registered and compared.ConclusionsSATIE will investigate whether a two weeks short-course of intravenous antibiotics in patients with IE caused by gram-positive cocci, without signs of persistent infection, is not inferior in safety and efficacy to conventional antibiotic treatment (4–6 weeks).Trial registrationClinicalTrials.gov Identifier: NCT04222257 (January 7, 2020).EudraCT 2019–003358-10.

Neurological Outcomes of Patients With Mycotic Aneurysms in Infective Endocarditis

Mycotic aneurysms (MA) are rare neurovascular complications of infective endocarditis (IE). The natural history and outcomes of MA under contemporary medical therapy have not been well characterized. The purpose of this study is to describe treatments and outcomes of patients with ruptured and unruptured MA in IE, specifically in relation to medical versus surgical/endovascular treatment. Retrospective chart review was performed at 3 US academic medical centers of adult patients with IE and MA. Information was collected regarding risk factors, imaging, treatments, and outcomes, including ischemic stroke, intracerebral hemorrhage, MA size changes, and inhospital mortality. Thirty-five patients with IE had 63 MA. Nineteen patients had at least one ruptured MA; 13 patients underwent invasive treatment and 6 received antibiotics alone. Of 19 patients on antibiotics alone (6 with at least one ruptured MA and 13 with unruptured MA), 14 underwent repeat imaging and 5 had enlarging MA. Of 16 patients treated invasively, 2 had unruptured MA initially treated with antibiotics but ultimately underwent intervention. No MA ruptured after aneurysm discovery. Fifteen patients underwent cardiothoracic surgery (CTS), of which 11 had unsecured MA and 4 had secured MA. No patients suffered perioperiative neurological events attributable to their MA. Three patients treated with antibiotics alone and 3 patients treated invasively died from causes unrelated to their MAs. For patients with unruptured MA, treatment with antibiotics alone may have similar outcomes to invasive treatment. Further investigation is warranted to determine the risk of undergoing CTS with unsecured MA.

Added value of three-dimensional transesophageal echocardiography in management of mitral paravalvular leaks.

Prosthetic paravalvular leak (PVL) is a well-known serious complication following surgically as well as percutaneously implanted prosthetic valves. It usually happens due to incomplete sealing of the prosthetic ring to the native cardiac tissue whether immediately postoperative or considerably later as a complication of infective endocarditis, etc Surgery has been always the treatment of choice for clinically significant PVLs. However, percutaneous transcatheter closure therapy has become a successful alternative in carefully selected group of patients. Echocardiography is a cornerstone in the initial diagnosis, assessment of the severity and location of the PVL. Furthermore, it plays a crucial role in the assessment of the feasibility for percutaneous closure and during intra-procedural guidance. Transesophageal echocardiography (TEE) has the advantage over transthoracic echocardiography (TTE) of not being affected by the acoustic shadow of the mitral prosthesis that usually hides the regurgitation jets and makes TTE evaluation difficult. Three-dimensional (3D) TEE has been shown to provide better diagnostic accuracy compared to two-dimensional (2D) TEE as regard to evaluation of PVLs especially in patients with more than one PVL. This is due to better delineation of the location, shape, and size of the PVL and equally important during guiding the transcatheter percutaneous closure.

Surgical infective endocarditis and concurrent splenic abscess requiring splenectomy: a case series and review of the literature

Splenic abscess is an uncommon but serious complication of infective endocarditis (IE). The timing of surgical management of splenic abscess can be challenging when valve surgery is required. The American Heart Association (AHA) and the European Society of Cardiology (ESC) currently recommends splenectomy before valve replacement due to fear of reinfection of the heart valve; however, published data to support this recommendation are limited. In this series, we report outcomes for 5 patients with IE and splenic abscess who underwent valve replacement first, followed by splenectomy at a median of 19 days (range: 10–77 days) after valve surgery, with no recurrent infection of the new valve. Our experience and review of the available literature provide reassurance for splenectomy after valve surgery for IE.

Time-trend population analysis of the clinical and epidemiologic effect on pediatric infective endocarditis after change of antibiotic prophylaxis guidelines.

In 2007, antibiotic prophylaxis (AP) guidelines for infective endocarditis (IE) changed, but the possible influence on the annual incidences of pediatric IE is unclear. We studied the clinical and epidemiologic impact of AP change by comparing two time periods before and after change of AP guidelines in a tertiary care center as referral center for a total population of more than 4,500,000 inhabitants. After change of AP guidelines, twenty-five patients were diagnosed for IE at a median age of 6.9years (range 0.1-19.4, female 48%). Modified Duke criteria were fulfilled for definite (12/25; 48%), or probable IE (13/25; 52%). The frequency of IE (cases per 1000 hospitalized patients) increased from 0.37% (1995-2005) to 0.59% (2006-2017) [p = 0.152], the annual incidence of IE (cases per 1000 CHD patients, < 20years of age) increased from 0.195 ‰ to 0.399 ‰ [p = 0.072]. Postoperative IE (13/25; 52%), was associated mostly with prosthetic pulmonary valves (12/13; 92%). Pathogens were staphylococci spp. (8/25; 32%), streptococci spp. (7/25; 28%), HACEK (3/25; 12%), other (4/25; 16%), or culture-negative (3/25; 12%). Treatment included antibiotics (25/25; 100%), and cardiac surgery (16/25; 64%). The clinical findings and complications of pediatric IE including mortality (2/25; 8%) did not differ between the two time periods. Pediatric IE remains a severe cardiac disease with a comparable clinical picture. Unless increasing absolute case numbers of IE, the relative case number of IE remains stable despite AP change. The high number of prosthetic pulmonary valve associated IE needs further evaluation and therapeutic alternatives.

Infective Endocarditis in Pregnancy During the Opioid Epidemic [16E

INTRODUCTION: To compare the incidence and complications of infective endocarditis among opioid-using pregnant women from 2006–08 and 2016–18. METHODS: We conducted a cross-sectional analysis of hospitalizations using a publicly available, all-payer inpatient database in Kentucky. Duplicate patients were identified and removed. RESULTS: From 2006–08, 187,178 hospitalizations involved pregnancy of which 1,311 were diagnosed with opioid dependence, use, or abuse. Three of these women had ICD codes for endocarditis (0.23%). From 2016–18, 166,756 hospitalizations involved pregnancy, of which 5,222 were diagnosed with opioid dependence, use, or abuse (+398%). Three of these patients had rheumatic disease, leaving 37 patients (0.71%) with endocarditis related to their opioid use alone, P=.047. The 2016–18 population with endocarditis were white (100%); lived primarily in metropolitan counties (61%); and 57.1% were less than 30 years old. 11% of admissions were in the 1st trimester, 16.2% in the 2nd, 43.2% in the 3rd, and 16.2% postpartum, P=.012. 14% had a spontaneous or missed abortion. The median length of stay was 22.5 days. Ten deliveries were complicated by endocarditis, six by cesarean section. Five women underwent valvular surgery in 2016–18: four valve replacements and one total valve excision. Of the hospitalizations with a maternal mortality for 2016–18, three were complicated by endocarditis. CONCLUSION: A four-fold increase in hospitalization complicated by opioid use was observed as well as a significant increase in the rate of infective endocarditis in this population. Endocarditis contributed to maternal mortality, life-threatening morbidities, prolonged hospital stay, and increased cost.

Embolic risk stratification and prognostic impact of early surgery in left-sided infective endocarditis

In patients with left-sided infective endocarditis (IE) and heart failure associated with large vegetations, early surgery prevents embolic events. However, optimal timing of surgery for other indications is still unresolved particularly when the presence of large vegetations represents the sole indication. We retrospectively analyzed 308 consecutive patients admitted to our department with definite left-sided IE. Of these patients, 243 (79%) underwent cardiac surgery (complicated IE), 34 patients with uncomplicated IE received medical treatment, 24 were not operated due to prohibitive general conditions and 7 refused surgery. Long-term follow-up was obtained by structured telephone interviews. During the 6-year follow-up (average 121.8 weeks ± 76), patients not operated because of general conditions or refusal had the worst prognosis, while outcome in operated patients for complicated IE was comparable to that of uncomplicated IE treated medically. Early (<2 weeks from diagnosis) surgery was associated with better survival compared to delayed surgery (HR 0.58, p=0.23). Embolic events were detected at admission in 38% of cases; Staphylococcus Aureus etiology and vegetation size were independently associated with embolism (OR 2.4, p=0.01; OR 1, p=0.008 respectively). Compared to uncomplicated medically-treated patients, complicated IE showed comparable survival when managed aggressively by surgical intervention, whereas a conservative approach was associated with an adverse prognosis. Staphylococcus Aureus infection and vegetation size were independent predictors of systemic embolism. Our data support aggressive surgical management of complicated IE patients and highlight the importance of etiological characterization in clinical decision-making.

Personality Disorder as the Initial Presentation of a Complicated Endocarditis: Diagnostic Challenges in the CARDIO-PSYCHIATRY

Background: Bacterial endocarditis is a rare infectious entity with a very heterogeneous clinical spectrum; neurological manifestations are the most frequent and serious extracardiac complications of infective endocarditis. However, little is known about the psychiatric manifestations and / or sequels due to septic embolism of the infective endocarditis. Case Report: 50-year-old male, history of arterial hypertension and nephrolithiasis with recurrent urinary tract infections. He began his condition with behavioral changes characterized by marked impulsivity and instability in his interpersonal relationships, adding repetitive events of fever and nephrolithiasis requiring urological interventions and antibiotic therapy. Upon admission assessed by psychiatry because of his impulsive behavior and emotional changes with the presumptive diagnosis of borderline personality disorder. Conclusion: In the following work we describe the first case found in the literature of a psychiatric manifestation in a male patient as the initial complication of a subacute bacterial endocarditis, his diagnostic approach, clinical picture and therapeutic outcome. The early recognition of the clinical picture and the diagnostic approach allowed to establish effective antibiotic treatment; to recognize that bacterial endocarditis might present in a multifaceted way allows to suspect this disease and give treatment opportunely to reduce its burden and mortality.

PERIVALVULAR ABSCESS PRESENTING AS REDUCTION IN DEGREE OF AORTIC STENOSIS

Perivalvular abscess and acute valve dysfunction are serious complications of infective endocarditis (IE). A 71 year old with severe aortic stenosis (AS) and prior E. faecalis bacteremia presented with recurrent decompensated heart failure. An echocardiogram (TTE) two months prior showed a

A HOLE IN THE PARADIGM: INFECTIVE ENDOCARDITIS COMPLICATED BY A GERBODE-TYPE DEFECT

A Gerbode-type defect, a ventricular septal defect communicating between the left ventricle (LV) and right atrium (RA), is a rare complication of infective endocarditis (IE) and often mistaken for severe pulmonary hypertension leading to a delay in diagnosis. An 85 year old female presented in 3rd

Acute Ischemic Stroke Treatment in Infective Endocarditis: Systematic Review

Background: Ischemic stroke is a frequent neurologic complication of infective endocarditis. This systematic review aims to evaluate the efficacy and safety of thrombectomy in comparison to thrombolysis and to combined treatment in patients with infective endocarditis associated acute ischemic stroke. Methods: A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review included case reports, cases series, cross-sectional studies, case control studies, randomized controlled trials or nonrandomized controlled trials, which reported the treatment of endocarditis-related acute ischemic stroke with mechanical thrombectomy, intravenous or intra-arterial thrombolysis in adult patients. Data sources: Scielo, b-on, Pubmed and Cochrane, from inception to April 2019. Reference lists were also checked. We compared the efficacy (independence, neurological improvement) and safety (intracranial bleeding, death) of acute ischemic stroke treatment with thrombolysis, thrombectomy and combined therapy. Results: Through systematic review 37 articles describing 52 patients met criteria. The risk of intracranial hemorrhage was 4.14 times higher in patients treated with intravenous thrombolysis (P = .001) and 4.67 times higher in patients treated with combined treatment (P = .01). There was trend for independence (P = .09) and neurological improvement (P = .07) in favor of thrombectomy, when comparing this group to the group treated with intravenous thrombolysis. Conclusions: With the limitation of the low quality of the available evidence, thrombectomy in infective endocarditis associated stroke appears to be safer than thrombolysis, or combined treatment. These results may be useful to guide clinical decisions, in selected patients.

High level of D-dimer predicts ischemic stroke in patients with infective endocarditis.

BackgroundIschemic stroke is one of the most prominent and serious neurological complications of infective endocarditis (IE). Our study was designed to evaluate the predictive value of higher level of plasma D‐dimer on admission for the development of ischemic stroke in patients with IE.MethodsIn this prospective study, a total of 173 consecutive patients with IE were recruited from January 2016 to December 2018. Plasma D‐dimer and other clinical indexes of IE patients were measured after admission. The number of patients who developed ischemic stroke during 6‐month follow‐up was recorded, as well as the occurrence time of ischemic stroke.ResultsIschemic stroke was observed in 38 (22%) patients during 6‐month follow‐up since definite diagnosis of IE. Patients with ischemic stroke had significantly higher levels of plasma D‐dimer than those of patients without stroke (4982 vs 2205 μg/L, P < .001). In addition, Staphylococcus aureus infection (HR: 1.96, 95% CI: 1.51‐2.42), mitral valve vegetation (HR: 1.52, 95% CI: 1.32‐1.75), and higher levels of on‐admission plasma D‐dimer (HR: 1.35, 95% CI: 1.27‐1.43) were significantly associated with ischemic stroke. Moreover, D‐dimer levels ≥3393 μg/L served as a strong predictor for ischemic stroke in patients with IE, and the sensitivity and specificity were 78% and 83%, respectively.ConclusionOur study suggested that higher level of D‐dimer on admission was an independent predictor for ischemic stroke in patients with IE. These patients may require special attention, in particular within the first trimester after IE diagnosis.

Gender differences in clinical features and complications of infective endocarditis: 11-year experience of a single institute in Egypt

BackgroundNo data exists about the gender differences among patients with infective endocarditis (IE) in Egypt. The objective was to study possible gender differences in clinical profiles and outcomes of patients in the IE registry of a tertiary care center over 11 years.ResultsThe IE registry included 398 patients with a median age of 30 years (interquartile range, 15 years); 61.1% were males. Males were significantly older than females. Malignancy and recent culprit procedures were more common in females while chronic liver disease and intravenous drug abuse (IVDU) were more in males. IE on top of structurally normal hearts was significantly more in males (25.6% vs 13.6%, p = 0.005) while rheumatic valvular disease was more common in females (46.3% vs 29.9%, p = 0.001). There was no difference in the duration of illness before presentation to our institution. The overall complication rate was high but significantly higher in females. However, there were no significant differences in the major complications: mortality, fulminant sepsis, renal failure requiring dialysis, heart failure class III–IV, or major cerebrovascular emboli.ConclusionIn this registry, IE occurred predominantly in males. Females were significantly younger at presentation. History of recent culprit procedures was more common in females while IVDU was more common in males who had a higher incidence of IE on structurally normal hearts. The overall complication rate was higher in women. IE management and its outcomes were similar in both genders.

Mitral Valve Aneurysm in Mitral Valve Endocarditis: A Case Report

Mitral valve aneurysm (MVA) is an ominous complication of infective endocarditis (IE), with worse outcomes seen among patients with preexisting valvular disease or intravenous drug use. Valve aneurysms can perforate or lead to rupture of the chordae tendineae, with the consequent development of severe mitral regurgitation and acute pulmonary edema. We present a case of a 54-year-old woman with hypertension, obesity, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease, peptic ulcer disease, obstructive sleep apnea, gastroesophageal reflux disease, intravenous drug abuse and bipolar disorder who developed MVA one month after being discharged for IE. Decline in the clinical status of patients with IE is a troubling sign that may indicate an IE complication such as MVA. Physicians should diligently monitor patients with IE for changes in signs and symptoms, as early recognition and surgical intervention are key to prevent further morbidity and mortality.

P228 Mitral valve aneurysm in the context of post-infective endocarditis in hypertrophic cardiomyopathy: an issue of inflammation or pressure gradients?

Abstract Mitral valve aneurysms (MVA) are uncommon and usually develop acutely in the setting of infective endocarditis (IE). We present a case report of a patient with a ruptured aneurysm of the mitral valve (MV) leaflet and obstructive hypertrophic cardiomyopathy (HCM), previously treated for IE. Echocardiography is essential for diagnosis, highlighting the importance of imaging for early identification and timely intervention. CASE REPORT 68-year-old male patient with type 2 diabetes mellitus and dyslipidemia was admitted to hospital with a 3-week history of malaise, fever and recent left-sided abdominal pain. No past relevant history. Physical examination revealed a grade II/VI systolic heart murmur at the cardiac apex, fever, abdominal tenderness in the left upper quadrant and purpuric lesions in the inferior limbs. Neutrophilia, CPR 211mg/L. Positive blood cultures for Staphylococcus aureus methicillin-sensitive. Spleen embolization, with no abcess on abdominal CT. Transthoracic (TTE) and transesophageal echocardiography (TEE) disclosed a highly mobile polypoid mass in the atrial side of the anterior MV leaflet, septal left ventricular hypertrophy and systolic anterior motion (SAM) of the MV. Mild mitral regurgitation (MR). No evidence of abcess, aneurysm or valve perforation. The diagnosis of IE was established and the patient completed 42 days of Flucloxaciline. Favorable clinical evolution, residual lesions on the MV. TTE and TEE were repeated on follow-up. Besides HCM and SAM of the MV, an aneurysm of the anterior leaflet of the MV was identified and two regurgitant jets: one due to incomplete coaptation of the leaflets; other through the perforated aneurysm. Mild global MR. A strategy of close follow-up was adopted. Beta blocker dose was increased. Maintenance of the characteristics of the aneurysm. DISCUSSION MVA are rare, with perforation and significant MR development as the most serious complications. They mostly develop in the acute setting of IE of the aortic valve (AV), due to the "jet lesion" from the regurgitant jet or direct extension of the infection. In this case, MVA developed as a late complication of IE of the MV. Previous infection and inflammation lead to increased susceptibility of the valve leaflet, with possible persistent chronic inflammation. In the setting of obstructive HCM, the lesioned endothelium is exposed to significant intraventricular pressure gradients, which have probably raised its propensity to bulge towards the atrium, resulting in aneurysm formation and perforation. Optimal approach to MVA has not been defined. If the setting of perforation with severe MR, surgery must be performed in order to avoid a fatal outcome. In small aneurysms with mild MR, a conservative approach seems reasonable. The purpose of this case is to highlight potential complications of IE, which should be actively investigated, with echocardiography playing a central role in the diagnosis and follow-up.

P1474 Right or left; which sided the infective endocarditis is?

Abstract ABSTRACT Treatment and management of infective endocarditis (IE) depends on the side of involvement. Involvement of both sides of heart is rarely encountered. We describe one case of both sided infective endocarditis caused by staphylococcus auerus. In this case, the vegetation is thought to be on the right side of the heart at first examination by transthrorasic echocardiography (TTE). However; when examined more carefully with transoesophageal echocardiography (TEE), nothing was as it seemed. CASE PRESENTATİON A 86-year-old woman, who underwent mechanic aortic valve replacement surgery 11 years before, was admitted to emergency room with fever, dispnea and cough. Physical examination showed a temperature of 38.6. Electrocardiography showed a atrial fibrillation of 112 beats/min. Laboratory tests revealed an elevated C reactive protein of 211 mg/l. The patient was empirically treated with intravenous piperacillin-tazobactam and teicoplanin, by the recommendation of infection disease unit. Staphylococcus aureus grew in both bottles of blood cultures. A TTE showed severe tricuspid regurgitation with vegetation, mild aortic regurgitation and moderate mitral regurgitation with no clear vegetation. We decided perform TEE and realised the vegetation in the right atrium was originated from the right atrial wall not from the tricuspid valve. Then we also noticed a thickening in the walls of aortic root with systolic expansion. This finding was consistent with paraaortic abscess formation. The 3D TEE examination helped us to understand the origin of the vegetation in the right atrium. Because the wall of the right atrium which the vegetation arised from was in direct continuity with the infected aortic root. We conclude that the paraortic abscess was spread to the right atrium by neighborhood. After one week of IV antibiotics treatment, the patient undergone open heart surgery. The surgical inspection confirmed the echocardiographic diagnosis. DISCUSSION Echocardiography helps us in diagnosis, determination of side of involvement, and complications of infective endocarditis. Usually the endocarditis invole only one side of the heart: left or right. We have found only four cases of double-sided endocarditis in literature. Our case is the first one , in which we describe a direct extension of aortic root abscess to the right atrium. Abstract P1474 figure 1

P222 Pycnodysostosis and cardiac congenital defects: a rare association

Abstract Introduction Pycnodysostosis is a rare recessive autosomal hereditary disease associated with skeletal dysplasia, with no evidence of associated cardiac defects. Clinical case The authors report a case of a 29-years old male patient with previous diagnosis of pycnodysostosis and a corrected subaortic ventricular septal defect. He was admitted at the emergency room due to productive cough with purulent expectoration which started one week before, refractory to the first antimicrobial therapy. The patient evolved with respiratory failure and necessity of orotracheal intubation and invasive mechanical ventilation. Large spectrum antimicrobial therapy was initiated after blood cultures and serologies for atypical agents of pneumonia collection (all negative). Due to the persistence of fever and elevation of inflammatory parameters, a transthoracic echocardiogram was performed to evaluate the presence of vegetations or other complications of infective endocarditis, not excluding this hypothesis. A transesophageal echocardiogram (TEE) was then performed showing a severe dysplastic mitral valve with flail of both leaflets conditioning a torrential mitral regurgitation occupying all the left atrium; and a tricuspid valve also dysplastic with no significant regurgitation. The patient was proposed to cardiac surgery. Intraoperative TEE revealed mitral dysplastic leaflets both inserted in a single papillary muscle constituting a congenital abnormally designated parachute mitral valve presenting with torrential mitral regurgitation and no images suggestive of vegetations neither other complications. A mechanical prothesis was successfully implanted in mitral position with subsequent favorable clinical evolution. Conclusion In this case, the authors report two concomitant rare congenital abnormalities: one in the mitral valve and the other affecting the skeletal system, which are usually not associated. Abstract P222 Figure.

Epidemiological and microbiological characteristics and complications of infective endocarditis in children

Despite the progress in diagnostic modalities and therapeutic strategies, Infective endocarditis remains a lethal disease especially in children. We aimed to update current characteristics of infective endocarditis in children and to identify complications. We carried out in our department a retrospective study including 40 children diagnosed with infective endocarditis (IE) between 1983 and 2017. Forty children with IE were diagnosed by using modified Ducke criteria. There were 19 boys and 21 girls aged between 1 to 18 years. Sixteen children (40%) had congenital heart disease including inter ventricular septal defect, tetralogy of Fallot, patent ductus arteriosis. Left-side IE occurred in 33 patients (82.5%). There was no case of IE of prosthetic valve. Streptococcus viridans were identified in 4 patients and Staphylococcus aureus in 5 patients. Blood culture-negative IE was concluded in the other cases. Neurological complications occurred in 9 patients, including 5 with cerebral infarction and 3 with intra cerebral bleeding. Clinical signs of cerebral stroke were hemiparesis (63%), facial paralysis (18%) and speech disorder (27%). One case of pulmonary embolism was identified and 3 cases of splenic infraction. The mortality in children with IE was important (50%). The mortality rate in patients who had cerebral stroke was significantly higher than those who had not (75% versus 35%, P < 0.05). In our study, IE in child has various characteristics compared to IE in adult. IE complication increases the risk of death.

Mycotic aneurysm and infective endocarditis: Data from a French bi-center study of 2483 patients

Mycotic aneurysm (MA) is rare but is a serious complication of infective endocarditis (IE). To evaluate the epidemiological, microbiological, diagnostic, therapeutic and prognostic data of patients with this complication. In a French bi-center prospective study of patients who presented in our endocarditis reference centers with a diagnosis of definite IE from 1988 to 2017 ( n = 2483), 101 (4%) presented MA. Patients with MA were younger (56 vs. 67y, P < 0.001), more often male (83% vs. 71%, P = 0.007), intravenous drug users (13% vs. 5%, P < 0.001). Diabetes (5% vs. 15%, P = 0.004), neoplasia (9% vs. 16%, P = 0.049), history of valve replacement (31% vs. 21%, P = 0.031) and cardiac device (5% vs. 20%, P < 0.001) were less frequent in MA group. Positive blood cultures were more frequent in MA group (97% vs. 81%). MA group had more aortic and mitral location (63% vs. 48%, p = 0.006 and 53% vs. 42%, P = 0,034, respectively) with more aortic perforation (25% vs. 14%, P = 0.002). Septic emboli were more frequents in MA group (81% vs. 41%, P < 0.001) regarding cerebral septic emboli (57% vs. 17%, P < 0.001), non-cerebral emboli (39% vs. 22%, p < 0.001) and multiple septic emboli (25% vs. 8%, P < 0.001). MA group had more cerebral events: ischemic stroke (33% vs. 12%, P < 0.001), intracranial hemorrhage (33% vs. 3%, P < 0.001). The indication of cardiac surgery was more frequent in the MA group (83% vs. 70%, P = 0.007) but the delay to surgery was longer (20 vs. 13 days, P = 0.029). Regarding the evolution, MA group had higher in-hospital mortality (22% vs. 13%, p0.014) and poorer 1-month survival (65% vs. 80%, P = 0.045) but the one-year mortality did not differ (52% vs. 49%, P = 0.79). Our data highlight that MA in IE is associated with poor short-term prognosis, mainly due to neurological complications in his younger population. One of the future challenges should be the improvement of the diagnostic of MA in IE.