Definite Infective Endocarditis Research Articles

Comparison of the 2015 and 2023 European Society of Cardiology versions of the Duke criteria among patients with suspected infective endocarditis.

Diagnosing infective endocarditis (IE) poses a significant challenge. This study aimed to compare the diagnostic accuracy of the 2015 and 2023 Duke clinical criteria introduced by the European Society of Cardiology (ESC) in a cohort of patients suspected of having IE. Conducted retrospectively at two Swiss University Hospitals between 2014-2023, the study involved patients with suspected IE. Each hospitals' Endocarditis Team categorized case as either IE or not IE. The performance of each iteration of the Duke-ESC clinical criteria was assessed based on the agreement between definite IE and the diagnoses made by the Endocarditis Team. Among the 3127 episodes with suspected IE, 1177 (38%) were confirmed to have IE. Using the 2015 Duke-ESC clinical criteria, 707 (23%) episodes were deemed definite IE, with 696 (98%) receiving a final IE diagnosis. With the 2023 Duke-ESC clinical criteria, 855 (27%) episodes were classified as definite IE, of which 813 (95%) were confirmed as IE. The 2015 and 2023 Duke-ESC clinical criteria categorized 1039 (33%) and 1034 (33%) episodes, respectively, as possible IE. Sensitivity for the 2015 Duke-ESC and the 2023 Duke-ESC clinical criteria was calculated at 59% (95% CI: 56-62%), and 69% (66-72%), respectively, with specificity at 99% (99-100%), and 98% (97-98%), respectively. The 2023 ESC criteria demonstrated significant improvements in sensitivity compared to the 2015 version, although one-third of episodes were classified as possible IE by both versions.

Low rates of complications and β-lactam resistance in viridans group streptococci bloodstream infection among cancer patients receiving chemotherapy.

Viridans group streptococci (VGS) bloodstream infection (BSI) frequently occurs in cancer patients receiving chemotherapy, and is associated with infective endocarditis (IE) in up to 20% of cases in the general population. In cancer patients receiving chemotherapy with VGS BSI, we aimed to: (i) determine the incidence of infective complications including IE, (ii) assess the utility of echocardiography in this patient population, (iii) determine the duration and type of antimicrobial therapy received for monomicrobial infections, and (iv) determine the evolution of antimicrobial resistance. VGS BSIs (excluding Streptococcus pneumoniae and Streptococcus pseudopneumoniae) in cancer patients receiving chemotherapy were identified from a statewide public pathology database between 2013 and 2022 at our tertiary centre. Medical records were accessed for clinical, microbiological and radiological data. Of 581 patient episodes screened, 183 episodes involving 171 patients met inclusion criteria. Of these, 51% were bone marrow transplantation (BMT) patients, 40% were non-BMT haematology patients, and 8% were solid organ malignancy patients. The median age was 55 years, and 96% were neutropenic at the time of blood culture collection. A transthoracic echocardiogram was performed for 71% of episodes, and one patient met modified Duke's criteria for definite IE, although this diagnosis was not suspected on clinical grounds. Other complications were uncommon. Benzylpenicillin resistance was rare (2.9%) and did not change over time. Most episodes (75%) were treated with piperacillin/tazobactam. For monomicrobial BSIs, the median antibiotic duration was 5 days (IQR 2-7) post-neutropenia resolution. Infective complications and antimicrobial resistance are rare in cancer patients with VGS BSI. This may provide a safe opportunity to limit both investigations (e.g. echocardiogram) and prolonged exposure to broad-spectrum antimicrobials.

Outcomes of patients with definite and possible infective endocarditis related to a cardiac implantable electronic device.

Diagnosis of lead related infective endocarditis (LRIE) is often a real challenge. Current diagnostic criteria include LRIE definite and possible. Comparison of the outcomes of patients with definite and possible LRIE undergoing transvenous lead extraction (TLE) procedures. A retrospective analysis of data from 3782 patients undergoing TLE between 2006 and 2023 was performed. The study included 838 patients with definite and possible LRIE. The analysis of clinical data and short and long-term survival was performed. The comparison of clinical data showed more frequent occurrence of vegetations (81.58% vs 37.21%; P <0.001), positive blood cultures (66.12 % vs 51.64%; P <0.001) and septic pulmonary embolism (40.14% vs 13.78%; P <0.001) in patients with definite LRIE. Long-term mortality of patients with definite and possible LRIE (median follow up 4.61 [1.04-9.40] and 5.06 [2.07-8.75] years respectively) was 61.14% vs 49.29%; P <0.001. Predictors of mortality in patients with marked LRIE include advanced age, low left ventricular ejection fraction (LVEF), comorbidities, septic pulmonary embolism, positive blood culture, and the presence of an abandoned lead. In possible LRIE, only the influence of advanced age, low LVEF and comorbidities was demonstrated. There has been no documented direct impact of delayed diagnosis on the long-term survival of patients after TLE Conclusions: The study documented better survival in patients with possible LRIE, which confirms the need to use extended diagnostic criteria for LRIE. Implementation of appropriate treatment at an early stage of infection allows for improved prognosis.

Evaluation of the HANDOC score and the 2023 ISCVID and ESC Duke clinical criteria for the diagnosis of infective endocarditis among patients with streptococcal bacteremia.

Streptococci are a common cause of infective endocarditis (IE). We aimed to evaluate the performance of the HANDOC score to identify patients at high-risk for IE and the Duke clinical criteria of the European Society of Cardiology (ESC; 2015 and 2023 versions) and the 2023 version from the International Society of Cardiovascular Infectious Diseases (ISCVID) in diagnosing IE among patients with streptococcal bacteremia. This retrospective study included adult patients with streptococcal bacteremia hospitalized at Lausanne University Hospital. Episodes were classified as IE by the Endocarditis Team. A HANDOC score >2 classified patients as high-risk for IE. Among 851 episodes with streptococcal bacteremia, IE was diagnosed in 171 episodes (20%). Among 607 episodes with non-beta-hemolytic streptococci, 213 (35%) had HANDOC scores >2 points; 132 (22%) had IE. The sensitivity of the HANDOC score to identify episodes at high-risk for IE was 95% (90-98%), the specificity 82% (78-85%), and the NPV 98% (96-99%). 2015 Duke-ESC, 2023 Duke-ISCVID, and 2023 Duke-ESC clinical criteria classified 114 (13%), 145 (17%), and 126 (15%) episodes as definite IE, respectively. Sensitivity for the 2015 Duke-ESC, 2023 Duke-ISCVID, and 2023 Duke-ESC clinical criteria was calculated at 65% (57-72%), 81% (74-86%), and 73% (65-79%), respectively, with specificity at 100% (98-100%), 99% (98-100%), and 99% (98-100%), respectively. The HANDOC score showed an excellent NPV to identify episodes at high-risk for IE. Among the different versions of the Duke criteria, the 2023 Duke-ISCVID version fared better for the diagnosis of IE among streptococcal bacteremia.

Prediction of 30‐day mortality after surgery for infective endocarditis using risk scores: Insights from a European multicenter comparative validation study

BackgroundIt remains unclear today whether risk scores created specifically to predict early mortality after cardiac operations for infective endocarditis (IE) outperform or not the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II). MethodsPerioperative data and outcomes from a European multicenter series of patients undergoing surgery for definite IE were retrospectively reviewed. Only the cases with known pathogen and without missing values for all considered variables were retained for analyses. A comparative validation of EuroSCORE II and five specific risk scores for early mortality after surgery for IE – (1) STS-IE (Society of Thoracic Surgeons for IE); (2) PALSUSE (Prosthetic valve, Age ≥70, Large intra-cardiac destruction, Staphylococcus spp, Urgent surgery, Sex (female), EuroSCORE ≥10); (3) ANCLA (Anemia, New York Heart Association class IV, Critical state, Large intra-cardiac destruction, surgery on thoracic Aorta); (4) AEPEI II (Association pour l’Étude et la Prévention de l'Endocardite Infectieuse II); (5) APORTEI (Análisis de los factores PROnósticos en el Tratamiento quirúrgico de la Endocarditis Infecciosa) – was carried out using calibration plot and receiver-operating characteristic curve analysis. Areas under the curve (AUCs) were compared 1:1 according to the Hanley-McNeil's method. The agreement between APORTEI score and EuroSCORE II of the 30-day mortality prediction after surgery was also appraised. ResultsA total of 1,012 patients from five European university-affiliated centers underwent 1,036 cardiac operations, with a 30-day mortality after surgery of 9.7%. All IE-specific risk scores considered achieved better results than EuroSCORE II in terms of calibration; AEPEI II and APORTEI score showed the best performances. Despite poor calibration, EuroSCORE II overcame in discrimination every specific risk score (AUC, 0.751 vs. 0.693 or less, p=0.01 or less). For a higher/lesser than 20% expected mortality, the agreement of prediction between APORTEI score and EuroSCORE II was 86%. ConclusionEuroSCORE II discrimination for 30-day mortality after surgery for IE was higher than five established IE-specific risk scores. AEPEI II and APORTEI score showed the best results in terms of calibration.

Lower specificity of the ESC2023 diagnostic criteria for infective endocarditis when spondylodiscitis is regarded as a vascular phenomenon.

The ESC diagnostic criteria for infective endocarditis (IE) added spondylodiscitis as minor diagnostic criterion. Of patients with Staphylococcus aureus, streptococcal or Enterococcus faecalis bacteremia, 11 of 1807 episodes were reclassified to definite IE of which nine were not treated as IE. Spondylodiscitis as a minor criterion decreases specificity of the criteria.

Non-betahemolytic streptococcal bacteremia, cardiac implantable electronic device, endocarditis, extraction, and outcome; a population-based retrospective cohort study.

Patients with non-beta-hemolytic streptococcal bacteremia (NBHSB) are at risk of infective endocarditis (IE). Patients with cardiac implantable electronic device (CIED) have been described to have an increased risk of IE. The aim of the study was to describe a population-based cohort of patients with NBHSB and CIED and variables associated with IE and recurrent NBHSB. All episodes with NBHSB in blood culture from 2015 to 2018 in a population of 1.3 million inhabitants were collected from the Clinical Microbiology Laboratory, Lund, Sweden. Through medical records, patients with CIED during NBHSB were identified and clinical data were collected. Patients were followed 365days after NBHSB. Eighty-five episodes in 79 patients with CIED and NBHSB constituted the cohort. Eight patients (10%) were diagnosed with definite IE during the first episode, five of whom also had heart valve prosthesis (HVP). In 39 patients (49%) transesophageal echocardiography (TEE) was performed of which six indicated IE. Four patients had the CIED extracted. Twenty-four patients did not survive (30%) the study period. Four patients had a recurrent infection with NBHSB with the same species, three of whom had HVP and had been evaluated with TEE with a negative result during the first episode and diagnosed with IE during the recurrency. The study did not find a high risk of IE in patients with NBHSB and CIED. Most cases of IE were in conjunction with a simultaneous HVP. A management algorithm is suggested.

Impact of the SARS-CoV-2 Pandemic on the Management and Prognosis of Infective Endocarditis.

Infective endocarditis (IE) is a serious condition which is difficult to diagnose and to treat, both medically and surgically. The objective of this study was to evaluate the impact of the SARS-CoV-2 pandemic on the management of patients with IE. We conducted a single-centre retrospective study including patients hospitalized for IE during the pandemic (Group 2) compared with the same period the year before (Group 1). We compared clinical, laboratory, imagery, therapeutic, and patient outcomes between the two groups. A total of 283 patients were managed for possible or definite IE (164 in Group 1 and 119 in Group 2). There were more intravenous drug-related IE patients in Group 2 (p = 0.009). There was no significant difference in surgery including intra-cardiac device extraction (p = 0.412) or time to surgery (p = 0.894). The one-year mortality was similar in both groups (16% versus 17.7%, p = 0.704). The recurrence rate was not significantly different between the two groups (5.9% in Group 2 versus 9.1% in Group 1, p = 0.311). The SARS-CoV-2 pandemic did not appear to have had a negative impact on the management of patients with IE. Maintenance of the activities of the endocarditis team within the referral centre probably contributed to this result. Nevertheless, the high proportion of intravenous drug-addicted patients in the pandemic cohort suggests that the SARS-CoV-2 pandemic had a major psychosocial impact.

Clinical Profile and Prognosis of Patients with Left-Sided Infective Endocarditis with Surgical Indication Who Are Not Operated.

Approximately a quarter of patients with infective endocarditis (IE) who have surgical indication only receive antibiotic treatment. Their short-term prognosis is dismal. We aimed to describe the characteristics of this group of patients to evaluate the mortality according to the cause of rejection and type of surgical indication and to analyze their prognostic factors of mortality. From 2005 to 2022, 1105 patients with definite left-sided IE were consecutively attended in three tertiary hospitals. Of them, 912 (82.5%) had formal surgical indication according to the most recent European Guidelines available in each period of the study and 303 (33%) only received medical treatment. These were older, had more comorbidities and higher in-hospital (46% vs. 24%; p < 0.001) and one year mortality (57.1% vs. 27.6%; p < 0.001) than operated patients. The main reason for surgical rejection was high surgical risk (57.1%) and the highest mortality when the cause were severe neurological conditions (76%). When the endocarditis team took the decision not to operate (25.5% of the patients), in-hospital (7%) and one-year mortality (17%) were low. In-hospital mortality associated with each surgical indication was 67% in heart failure, 53% in uncontrolled infection and 45% in prevention of embolisms (p < 0.001). Heart failure (OR: 2.26 CI95%: 1.29-3.96; p = 0.005), Staphylococcus aureus (OR: 3.17; CI95%: 1.72-5.86; p < 0.001) and persistent infection (OR: 5.07 CI95%: 2.85-9.03) are the independent risk factors of in-hospital mortality. One third of the patients with left-sided IE and formal surgical indication are rejected for surgery. In-hospital mortality is very high, especially when heart failure is the indication for surgery and when severe neurological conditions the reason for rejection. Short term prognosis of patients rejected by a specialized endocarditis team is favorable.

Endocardite infectieuse : facteurs prédictifs de mortalité intrahospitalière

IntroductionInfective endocarditis (IE) remains a serious disease with significant morbidity and mortality despite therapeutic advancements. The aim of our study was to determine the predictive factors of in-hospital mortality. Patients and methodsA prospective comparative study over a period of 54 months was conducted, including all patients admitted for definite infective endocarditis, diagnosed according to the modified Duke criteria published in 2015 by the European Society of Cardiology. ResultsThirty-four patients were included. Drug addiction was the main risk factor for infective endocarditis (56%). Tricuspid valve involvement was predominant (50%). Staphylococcus aureus was the most commonly isolated pathogen (65%). In-hospital mortality rate was 47%. In multivariate analysis, predictive factors for mortality were acute heart failure (OR=7.4; p=0.026; 95% CI [1.2–44]) and cerebral embolic localization (OR=11.1; p=0.024; 95% CI [13–90]). ConclusionsCardiac and cerebral complications influence the prognosis of IE. Thus, close collaboration among multidisciplinary teams is necessary for improved diagnostic and therapeutic management.

Differential in vitro susceptibility to ampicillin/ceftriaxone combination therapy among Enterococcus faecalis infective endocarditis clinical isolates.

To investigate the genomic diversity and β-lactam susceptibilities of Enterococcus faecalis collected from patients with infective endocarditis (IE). We collected 60 contemporary E. faecalis isolates from definite or probable IE cases identified between 2018 and 2021 at the University of Pittsburgh Medical Center. We used whole-genome sequencing to study bacterial genomic diversity and employed antibiotic checkerboard assays and a one-compartment pharmacokinetic-pharmacodynamic (PK/PD) model to investigate bacterial susceptibility to ampicillin and ceftriaxone both alone and in combination. Genetically diverse E. faecalis were collected, however, isolates belonging to two STs, ST6 and ST179, were collected from 21/60 (35%) IE patients. All ST6 isolates encoded a previously described mutation upstream of penicillin-binding protein 4 (pbp4) that is associated with pbp4 overexpression. ST6 isolates had higher ceftriaxone MICs and higher fractional inhibitory concentration index values for ampicillin and ceftriaxone (AC) compared to other isolates, suggesting diminished in vitro AC synergy against this lineage. Introduction of the pbp4 upstream mutation found among ST6 isolates caused increased ceftriaxone resistance in a laboratory E. faecalis isolate. PK/PD testing showed that a representative ST6 isolate exhibited attenuated efficacy of AC combination therapy at humanized antibiotic exposures. We find evidence for diminished in vitro AC activity among a subset of E. faecalis IE isolates with increased pbp4 expression. These findings suggest that alternate antibiotic combinations against diverse contemporary E. faecalis IE isolates should be evaluated.

Performance of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Diagnostic Criteria for Infective Endocarditis in Relation to the Modified Duke Criteria and to Clinical Management-Reanalysis of Retrospective Bacteremia Cohorts.

Revised diagnostic criteria for infective endocarditis (IE), the 2023 Duke-ISCVID criteria, were recently presented and need validation. Here, we compare the 2000 modified Duke criteria for IE with Duke-ISCVID among patients with bacteremia and relate the diagnostic classification to IE treatment. We reanalyzed patient cohorts with Staphylococcus aureus, Staphylococcus lugdunensis, non-β-hemolytic streptococci, Streptococcus-like bacteria, Streptococcus dysgalactiae, Enterococcus faecalis, and HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) bacteremia. Episodes were classified as definite, possible, or rejected IE with the modified Duke and Duke-ISCVID criteria. Reclassification included the microbiology criteria, positron emission tomography-computed tomography, and cardiac implanted electronic devices. To calculate sensitivity, patients treated for IE were considered as having IE. In 4050 episodes of bacteremia, the modified Duke criteria assigned 307 episodes (7.6%) as definite IE, 1190 (29%) as possible IE, and 2553 (63%) as rejected IE. Using the Duke-ISCVID criteria, 13 episodes (0.3%) were reclassified from possible to definite IE, and 475 episodes (12%) were reclassified from rejected to possible IE. With the modified Duke criteria, 79 episodes that were treated as IE were classified as possible IE, and 11 of these episodes were reclassified to definite IE with Duke-ISCVID. Applying the decision to treat for IE as a reference standard, the sensitivity of the Duke-ISCVID criteria was 80%. None of the 475 episodes reclassified to possible IE were treated as IE. The Duke-ISCVID criteria reclassified a small proportion of episodes to definite IE at the expense of more episodes of possible IE. Future criteria should minimize the possible IE group while keeping or improving sensitivity.

Evaluation of the Specificity of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Classification for Infective Endocarditis.

The 2023 Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) classification is a new diagnostic tool for infective endocarditis, updating the 2000 modified Duke and the 2015 European Society for Cardiology (ESC) classifications. In comparison, its sensitivity is higher; however, its specificity remains to be evaluated and compared to that of the 2 other classifications in endocarditis suspected patients. We retrospectively collected the characteristics of patients hospitalized in Bichat University's Hospital, Paris, in 2021, who had been evaluated for clinical suspicion of endocarditis, have had at least a transthoracic echocardiography, 2 pairs of blood cultures, 3-month follow-up and in whom endocarditis diagnosis was finally rejected. All patients were classified by 2000 modified Duke, 2015 ESC and 2023 Duke-ISCVID, as though the endocarditis diagnosis had not been rejected. In total, 130 patients' charts were analyzed. Mean age was 62 years, 84 (64.6%) were male, 39 (30.0%) had prosthetic cardiac valve or valve repair, 21 (16.2%) cardiac implanted electronic device, and 30 (23.1%) other cardiac conditions. Overall, 5, 2, and 5 patients were falsely classified as definite endocarditis with the 2000 modified Duke, 2015 ESC, and 2023 Duke-ISCVID classifications, respectively. The corresponding specificities were 96.2% (95% confidence interval [CI] [90.8%, 98.6%]), 98.5% (95% CI [93.9%, 99.7%]), and 96.2% (95% CI [90.8%, 98.6%]). The rates of possible endocarditis were of 38%, 35%, and 35% in the 3 classifications, respectively. The 2023 Duke-ISCVID classification is highly specific for ruling out the diagnosis of definite infective endocarditis in patients who had been evaluated for IE.

Importance of experience in transoesophageal echocardiographic evaluation of vegetation size in patients with infective endocarditis: a reliability study

Abstract Aims Vegetation size assessed by transoesophageal echocardiography (TOE) is a decisive metric in guiding surgical intervention and prognosis in patients with definite infective endocarditis (IE). The aim of this study was to assess the impact of echocardiographic experience on the reliability and reproducibility of TOE measurements of vegetations in patients with IE. Methods and results Twenty-nine raters from a cardiac department at a tertiary centre were divided into three groups according to echocardiographic experience: experts, cardiologists, and novices. All raters were instructed to measure the maximum length of vegetations in 20 different TOE exams. Interrater agreement was evaluated using intraclass correlation coefficient (ICC), one-way analysis of variance, Kruskal–Wallis test, and Bland–Altmann plots. Reliability was assessed by minimal detectable change (MDC). All measurements were compared with the measured size agreed on by the multi-disciplinary IE team. There was an overall significant interrater variance between the three groups (P &amp;lt; 0.001). The variance was 10.1, 14.8, and 21.7 for the experts, cardiologists, and novices, respectively. ICC was excellent for experts (96.3%) and cardiologists (93.7%) and good for novices (84.6%). The three groups tended to measure smaller than the endocarditis team. MDC was 2.6 mm for experts, 3.3 mm for cardiologists, and 3.6 mm for novices. Conclusion The study showed good to excellent intraclass correlation but high dispersion in all groups. Variance decreased with higher experience. Our findings support current recommendations that complicated cases should be cared for by the multi-disciplinary endocarditis team and underline the importance of echocardiographic expertise when evaluating and measuring vegetations in patients with IE.

Can the Glasgow prognostic score predict ischemic stroke in patients with infective endocarditis?

The Glasgow prognosis score is a simple parameter calculated using serum levels of albumin and C-reactive protein. The aim of this study was to examine whether this parameter may predict ischemic stroke in patients with infective endocarditis. A total of 80 patients who were diagnosed with definitive infective endocarditis according to Duke criteria between 2016 and 2023 were included in the study. Glasgow prognosis score was based on serum levels of albumin and C-reactive protein. In imaging methods, patients were divided into two groups according to whether they had a stroke or not. These two groups were compared in terms of biochemical parameters, and infective endocarditis findings on echocardiography and Glasgow prognosis score. We found that the results were statistically similar except for serum C-reactive protein (Group 1: 54.9±71.1 and Group 2: 39±70.7; p=0.03), neutrophil (Group 1: 19.8±10.8*109/L and Group 2: 13.3±7.3*109/L; p=0.014), albumin (Group 1: 2.3±0.6 and Group 2: 2.8±0.5; p=0.03), and Glasgow prognosis score (Group 1: median 2, min.-max. (1-2) and Group 2: median 1, min.-max. (0-1); p=0.004). In the receiver operating characteristics analysis, Glasgow prognosis score had 82.4% sensitivity and 58.3% specificity in predicting ischemic stroke if the Glasgow prognosis score cutoff was ≥1. In multivariate logistic regression analysis, chronic renal failure [odds ratio (OR): 1.098; 95% confidence interval: 1.054-1.964; p=0.044], age (OR: 1.050; 95%CI 1.006-1.096; p=0.024), and Glasgow prognosis score (OR: 0.695; 95%CI 0.411-0.949; p=0.035) were independent variables in predicting ischemic stroke. High Glasgow prognosis score is an independent predictor of ischemic stroke in patients with infective endocarditis. Glasgow prognosis score, determined using albumin and C-reactive protein levels, is a simple and practical index for predicting the prognosis of patients hospitalized with infective endocarditis.

Performance of the SHARPEN Score and the Charlson Comorbidity Index for In-Hospital and Post-Discharge Mortality Prediction in Infective Endocarditis.

Central Illustration : Performance of the SHARPEN Score and the Charlson Comorbidity Index for In-Hospital and Post-Discharge Mortality Prediction in Infective Endocarditis. SHARPEN was the first dedicated score for in-hospital mortality prediction in infective endocarditis (IE) regardless of cardiac surgery. To analyze the ability of the SHARPEN score to predict in-hospital and post-discharge mortality and compare it with that of the Charlson comorbidity index (CCI). Retrospective cohort study including definite IE (Duke modified criteria) admissions from 2000 to 2016. The area under the ROC curve (AUC-ROC) was calculated to assess predictive ability. Kaplan-Meier curves and Cox regression was performed. P-value < 0.05 was considered statistically significant. We studied 179 hospital admissions. In-hospital mortality was 22.3%; 68 (38.0%) had cardiac surgery. Median (interquartile range, IQR) SHARPEN and CCI scores were 9(7-11) and 3(2-6), respectively. SHARPEN had better in-hospital mortality prediction than CCI in non-operated patients (AUC-ROC 0.77 vs. 0.62, p = 0.003); there was no difference in overall (p = 0.26) and in operated patients (p = 0.41). SHARPEN > 10 at admission was associated with decreased in-hospital survival in the overall (HR 3.87; p < 0.001), in non-operated (HR 3.46; p = 0.006) and operated (HR 6.86; p < 0.001) patients. CCI > 3 at admission was associated with worse in-hospital survival in the overall (HR 3.0; p = 0.002), and in operated patients (HR 5.57; p = 0.005), but not in non-operated patients (HR 2.13; p = 0.119). Post-discharge survival was worse in patients with SHARPEN > 10 (HR 3.11; p < 0.001) and CCI > 3 (HR 2.63; p < 0.001) at admission; however, there was no difference in predictive ability between these groups. SHARPEN was superior to CCI in predicting in-hospital mortality in non-operated patients. There was no difference between the scores regarding post-discharge mortality.

Clinical correlates of circulating small dense low-density lipoproteins in acute infective endocarditis.

Infective endocarditis (IE) is a complex thrombo-inflammatory disorder, the pathogenesis of which involves a multifaceted interplay between vascular damage and bacterial virulence factors. This study aimed to assess the prognostic role of small dense low-density lipoprotein (sdLDL) cholesterol in patients with IE and its correlation with various disease-related features. A cohort of 198 patients with definite IE was included in this study. Clinical, laboratory, and echocardiographic parameters were meticulously analyzed, with a specific focus on comorbidities. sdLDL levels were measured using stored plasma samples obtained upon admission during the acute phase of the disease. The median level of sdLDL was 24mg/dL [with an interquartile range of 17.9-35.2mg/dL], and this value showed a statistically significant positive correlation with LDL/HDL cholesterol and triglycerides (p < 0.01 for all). Furthermore, a remarkable inverse correlation between C-reactive protein and D-dimer levels was observed (p < 0.0001). Univariate analysis revealed that patients with sdLDL levels ≤ 24mg/dL had 2.75 times higher odds of in-hospital mortality (95% Confidence Interval:1.08-6.98, p = 0.031). In addition, nonsurvivors had significantly lower median sdLDL levels (19.7 vs. 26.0mg/dL, p = 0.041). Lower sdLDL levels were also associated with embolic complications, larger vegetation size, and positive blood cultures for Staphylococci (p = 0.019, p = 0.022, and p < 0.001, respectively). Low circulating sdLDL levels in the acute phase of IE were significantly correlated with unfavorable clinical outcomes. These results suggest that the sdLDL level may serve as an important marker of disease severity in IE and may represent a link between vascular damage, embolic complications, and disease progression.

NatIonal Danish endocarditis stUdieS – Design and objectives of the NIDUS registry

AimsThe National Danish endocarditis stUdieS (NIDUS) registry aims to investigate the mechanisms contributing to the increasing incidence of IE and to discover risk factors associated to the course, treatment and clinical outcomes of the disease. MethodsThe NIDUS registry was created to investigate a nationwide unselected group of patients hospitalized for infective endocarditis (IE). The National Danish healthcare registries have been queried for validated IE diagnosis codes (International Classification of Disease, 10th edition (ICD-10): DI33, DI38, and DI398). Subsequently, a team of 28 healthcare professionals, including experts in endocarditis, will systematically review and evaluate all identified patient records using the modified Duke Criteria and the 2015 European Society of Cardiology (ESC) modified diagnostic criteria. The registry will contain all cases with definite or possible IE found in primary data sources in Denmark between January 1, 2016, and December 31, 2021. We will gather individual patient data, such as clinical, microbiological, and echocardiographic characteristics, treatment regimens, and clinical outcomes. A digital data collection form will be used to the gathering of data. A sample of approximately 4,300 individual patients will be evaluated using primary data sources. Conclusion and perspectivesThe NIDUS registry will be the first comprehensive nationwide IE registry, contributing critical knowledge about the course, treatment, and clinical outcomes of the disease. Additionally, it will significantly aid in identifying areas in which future research is needed.

Role of thoracoabdominal imaging on diagnosis and management in patients with suspected infective endocarditis

Abstract Background/Introduction Embolic events (EEs) are a common complication of infective endocarditis (IE) and their presence can impact diagnosis and modify the therapeutic plan. Purpose The present study aimed to describe the role of thoracoabdominal imaging (TA-Im) on diagnosis and management of patients with suspected IE. Methods This study was conducted at a university hospital, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. Results Among 966 episodes with IE suspicion and TA-Im, 740 (77%) contrast-enhanced CT, 158 (16%) 18F-FDG PET/CT and 68 (7%) non-contrast-enhanced CT. The majority of patients (528; 55%) were without thoracoabdominal symptoms. At least one EE was found in 205 (21%) episodes. Based on TA-Im findings, the diagnosis was reclassified from rejected to possible or from possible to definite IE in 6 (1%) and 10 (1%) episodes, respectively [2 (0.5%) and 5 (1%) in asymptomatic episodes, respectively]. Table shows the type of embolic events and their impact on diagnosis in episodes with suspected IE. Among the 413 patients with possible or definite IE, at least one EE was found on TA-Im in 143 (35%) episodes. Together with the presence of left-side valvular vegetation &amp;gt;10mm, the results of TA-Im established a surgical indication (prevention of embolism) in 15 (4%) episodes, 7 of which were asymptomatic. Among the subgroup of episodes (n=127) with left-side vegetation &amp;gt;10mm, TA-Im established a surgical indication in 12% of episodes (15 patients), 10% among asymptomatic episodes (7 out of 73). Figure shows the changes in diagnostic classification and management due to TA-Im results in patients suspected (A) and those with IE (B). Conclusion TA-Im performed in asymptomatic patients with IE suspicion improved the diagnosis of IE in only a small proportion of patients; this proportion was similarly low in symptomatic patients. The role of systematic TA-Im in the clinical management of asymptomatic IE patients remains unclear, since it identified a new indication for valvular surgery in only a small proportion of patients. The scenario, where the benefit of TA-Im on management is a patient with a vegetation &amp;gt;10mm; in those patients, systematic TA-Im may lead to a new surgical indication in 10% of cases.Embolic eventsDiagnosis and mangement

Left-sided native valve infective endocarditis concomitant with severe valvular regurgitation: Prevalence, characteristics and prognostic factors

Abstract Background The characteristics of patients with left-sided native valve infective endocarditis and severe valvular regurgitation has never been studied. Purpose To analyze the prevalence of severe valvular regurgitation in patients with left-sided infective endocarditis, to describe in detail their characteristics and to determine the prognostic factors of these patients. Patients and methods We included in an ongoing multipurpose database, all patients with definite left-sided infective endocarditis admitted in three Spanish tertiary hospitals from 2005 to 2022. We describe the clinical, epidemiological, microbiological, echocardiographic characteristics of patients with severe valvular regurgitation and compared it with those without it. We also analyzed the independent factors of in-hospital mortality of these patients. Results Of a total of 874 patients with left-sided native valve infective endocarditis of our series, 564 had severe valvular regurgitation (65%). Comparison between patients with and without severe valvular regurgitation is shown in figure 1. Age (HR 1.035 95% CI 1.02-1.05), S. aureus (HR 2.26; 95% CI 1.26-4.1), vegetations (HR 3.7; 95% CI 1.2-11.4), heart failure (HR 2.76; 95% IC 1.5-5.1), renal failure (HR 3.1; 95% CI 1.9-4.9) and septic shock (HR 4.3; 95% CI 2.29-8) were the independent factors of in hospital mortality. On the contrary, cardiac surgery is an independent protector factor of mortality (HR 0.35; 95% CI 0.21-0.59). Conclusions A very high proportion of patients with definite left-sided infective endocarditis have severe valvular regurgitation in our series. Despite important epidemiological, clinical and echocardiographic differences with patients without it, the short-term prognosis is similar Surgery is an independent protective factor in these patients.