Endocarditis Team Research Articles

Optimizing outcomes in infective endocarditis: A comprehensive literature review.

Despite being rare, infective endocarditis (IE) is a life-threatening disease with poor prognosis. New diagnostic and therapeutic strategies are emerging; however, predisposing factors and microbiology of the disease are also changing with time. Because of this, there has been a lack of reduction in the disease's incidence and new challenges for clinicians have arisen such as an increasingly aging population and growing antimicrobial resistance. In this paper, we aim to provide an overview of the changing trends in IE, current diagnosis, and management strategies, as well as the emerging role of the infective endocarditis teams in the care of patients with this disease. A comprehensive electronic search was done utilizing PubMed, Ovid, SCOPUS, Embase and google scholar. The search terms included 'Endocarditis', 'IE', 'Infection', 'Vegetation', 'Duke criteria', 'native valve infection', 'prosthetic valve', 'valve infection', 'endocarditis outcome' and 'endocarditis bacteriology'. The references of the identified articles were then searched for any potential articles that can be included. The inclusion criteria were any article that discussed the evidence behind incidence and management of IE including the role of endocarditis team. The exclusion criteria were case reports, expert opinion, and editorials. All the relevant findings are summarized in specified tables and within appropriate sections. It is vital to determine the current trends in the epidemiology and microbiology of the condition so that the diagnostic threshold can be adapted, to identify new at-risk groups and achieve an accelerated evaluation strategy that allows for earlier diagnosis and treatment. Management of IE can benefit from the input of different specialties, such as cardiology, cardiothoracic surgery, infectious disease, and microbiology. Therefore, adopting a multidisciplinary approach towards treatment is crucial to reduce morbidity and mortality from preventable complications of this pathology.

Impact of the Iranian Registry of Infective Endocarditis (IRIE) and multidisciplinary team approach on patient management

Backgrounds The last 30 years have witnessed major improvements in understanding of all aspects of infective endocarditis (IE). The Iranian Registry of Infective Endocarditis (IRIE) was formed to address epidemiological aspects of IE vis-à-vis its main pathogens and underlying heart diseases over a 12-year period. Indeed, a multidisciplinary team (MDT) for IE was developed alongside. Methods In a longitudinal observational study, data of adult patients with definite or possible IE based on modified Duke criteria were collected from 2007 to 2016 in our tertiary centre, Iran. From 2016 until 2019, we run a prospective observational study using formation of an IE MDT to provide better patient management and compared data before and after this. Results Totally, 645 patients with mean age of 48 ± 17 years were enrolled. Data of 445 and 200 patients were compared before and after IRIE and MDT formation, respectively. We found significantly reduced type and number of applied antibiotics (p = 0.04) and higher rate of positive blood culture (p = 0.001). Hospital length of stay increased significantly after formation of the IRIE and IE MDT (p = 0.02). The rate of heart failure, new abscess formation and cerebral emboli were significantly decreased after IRIE and IE MDT (p < 0.001) and consequently in-hospital mortality reduced significantly (p = 0.05). Conclusion Developing national registries and MDTs has potential to enhance patient management and reduce IE burden. Our results demonstrated that establishment of the Iranian IRIE and IE MDT conferred better diagnoses, standardised treatments and significantly reduced cardiac and extra cardiac morbidity.

EACVI survey on the evaluation of infective endocarditis.

AimsTo evaluate the diagnosis and imaging of patients with suspected endocarditis and the management in routine clinical practice across Europe, the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities and multidisciplinary team was explored.Methods and resultsA total of 100 European Echocardiography Laboratories from 29 different countries responded to the survey, which consisted of 20 questions. For most of the use of echocardiography and advanced imaging, answers from the centres were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, two-thirds of centres report the use of a specific endocarditis team for decision-making. Echocardiography plays a key role in the diagnosis and management of endocarditis. Nuclear imaging modalities are broadly available among the centres and are mainly used in prosthetic valve endocarditis and cardiac device-related infective endocarditis. Computed tomography (CT) is widely available and used to assess for structural valve abnormalities, neurological complications, and to preoperative assessment of the coronary arteries. Most institutions provide structured patients follow-up following hospital discharge.ConclusionIn Europe, a relatively homogenous adherence to current recommendation was observed for most diagnostic and management including the follow-up of patients with endocarditis. Decision-making is most commonly performed by a multidisciplinary team. Echocardiography remains the first line and central imaging modality for patient diagnosis and assessment, but 60% of centres also commonly use CT, whilst positron emission tomography imaging is used in patients with prosthetic valve endocarditis or device infection.

P1266 Infectious endocarditis- still a diagnostic dilemma

Abstract INTRODUCTION Infectious endocarditis is still a challenge with a high mortality and complication rate despite the progress made in its management. DESCRIPTION OF CLINICAL CASE A 58 years old female, with a history of mitral and aortic mechanical prosthesis for rheumatic valvular disease and mitral infectious endocarditis with Aggregatibacter Actinomycetemcomita due to an apical abscess was referred to our service for persistent fever. The clinical examination revealed irregular mechanical prosthesis beats, with no heart murmurs and no signs of heart failure, but with a tender splenomegaly. The laboratory tests showed an inflammatory syndrome, but no positive blood cultures. An extensive panel for endocarditis was negative for Coxiella burnetii, Brucella Spp, Legionella Spp, Mycoplasma Spp and for the immunology markers (rheumatoid factor, antinuclear antibodies and anti-cardiolipin antibodies) ECG AF, 88 bpm, PVC bigeminy, LBBB. Infectious endocarditis was the most likely diagnosis considering the fever, the inflammatory syndrome, the presence of the mechanical valves and the history of endocarditis. An echocardiography was performed that showed a non-dilated left ventricle with a preserved EF, no aortic prosthesis dysfunction, nor mitral; a dilated RV with normal function, moderate tricuspid regurgitation, no intracardiac masses and no pericardial effusion. The TEE revealed no vegetation, no abscess or pseudoaneurysms and no dehiscence of the prosthetic valves. The Endocarditis Team was reunited and empirical antimicrobial therapies with Amoxiciline, Gentamicine and Cloxaciline for 6 weeks, as well as a PET scan were recommended. The PET-CT revealed abnormal fixation in the posterior-inferior part of the aortic valve. As we had only one major criterion and two minor criteria for the diagnosis of endocarditis a radiolabeled leukocytes SPECT CT that showed no pathological fixation was realised. The result was inconclusive as it was performed at the end of the antimicrobial treatment. A computed tomography of the brain, thorax, abdomen and pelvis didn’t reveal any vascular phenomena. The tender splenomegaly was secondary to two hemangiomas. Also a dental computed tomography revealed an apical abscess of 1.2 that was treated after discharge with antibiotic prophylaxis. DISCUSSION This clinical case confirms that the diagnosis on infectious endocarditis can be challenging in patients with prosthetic valves. The multimodality imaging is of major importance for the diagnosis of these patients. Additionally the microbiological criteria was not met in this case as it was a blood culture-negative endocarditis with a history of previous antibiotic therapy. CONCLUSION Our knowledge of infectious endocarditis is constantly evolving. Blood culture negative endocarditis accounts for one third of cases and is still a challenge. The Endocarditis Team and multimodality imaging play a central role in the diagnosis and treatment of these patients. Abstract P1266 Figure. PET-CT showing AV abnormal fixation

P1453 Unfortunate association between obstructive hypertrophic cardiomyopathy and infective endocarditis

Abstract Bacterial endocarditis is an uncommon, but potentially severe complication of hypertrophic cardiomyopathy (prevalence &amp;lt; 1%). We report the case of a 27-year-old woman, with low socioeconomic status, with hypertrophic cardiomyopathy, presenting with chest pain, dyspnoea at moderate effort, fever and chills. The transthoracic and transoesophageal echocardiography showed obstructive septal hypertrophic cardiomyopathy (interventricular septum of 38 mm, systolic anterior motion of the mitral valve, maximum gradient in the left ventricular outflow tract of 80 mmHg), vegetations of 10 mm, on the atrial and ventricular mitral leaflets sides, mitral valvular abcess, severe mitral regurgitation, flail of the noncoronarian aortic cusp (with a 10 mm vegetation), severe aortic regurgitation, basal SIV vegetation, pericardial effusion. The blood cultures were positive for Streptococcus mitis. The thoracic, abdominal, pelvin CT scan confirmed the diagnosis of mitral-aortic infective endocarditis , revealing also an abcess of the aortic root and multiple embolisations (spleen and right external iliac artery). The cranial CT scan was normal. At the evaluation of the foci sites, multiple dental foci were discovered and treated by multiple extractions. The endocarditis team recommended antibiotic treatment (with ampicillin), urgent bivalvular replacement (aortic and mitral valve) and septal myectomy. The surgical procedure was denied by the patient, which was after that voluntarily discharged from the hospital. The patient died from cardiac arrest (asystole) 11 days after the initial diagnosis. A severe association between obstructive hypertrophic cardiomyopathy and infective endocarditis with multiple complications can have an initial paucisymptomatic clinical presentation. The low socioeconomic status of the patient was correlated with inadequate oral hygiene, that was a negative prognostic factor in the outcome of the patient. It is possible that the integration of oral health in our national general health programs for people with low socioeconomic status, will decrease morbidity and improve the quality of life. Abstract P1453 Figure. picture clinical case

Infective endocarditis of partial atrioventricular septal defect: A case report

Introduction. Partial atrioventricular septal defect (AVSD) is a form of congenital heart disease (CHD) rarely detected in adults. Infective endocarditis represents a severe complication that carries a substantial risk. Case report. We here reported a case of a 43-year-old female with previously diagnosed adult CHD (partial AVSD and bicuspid aortic valve) presented to the hospital with fever and malaise 14 days prior to admission. On the lung computed tomography scan inflammatory consolidations were found and dual antibiotic therapy (ceftazidime and clarithromycin) was administered without significant regression of pulmonary inflammatory consolidations. The antibiotic treatment was continued with amoxicillin/clavulanic acid combined with levofloxacin and metronidazole. Transthoracic and transesophageal echocardiography revealed a large vegetation (dimension, 3.6 x 1.8 cm) attached to the septal leaflet of the tricuspid valve floating between right atrium and right ventricle through tricuspid valve with high embolic potential. Endocarditis team reached a decision for immediate surgical intervention. The operative findings revealed the partial AVSD, common atrioventricular valve with cleft of the anterior mitral leaflet in the A2 segment and detached and cleft septal leaflet of the tricuspid valve. Vegetation (size 4 x 3 cm) was attached to the septal side of the tricuspid annulus, basal segment of the anterior mitral leaflet and edge of the atrial septal defect freely floating between right atrium, right ventricle and left atrium. Excision of the vegetation and AVSD plastics were done, as well as the reconstruction of the mitral and tricuspid annuli and leaflets. The treatment was continued with antibiotics and completed in 18 days with full recovery. Conclusion. Early and precious diagnosis and optimal management that combines both conventional and surgical approaches are crucial for reducing the risk of complications and mortality in patients with infective endocarditis in grown-up congenital heart disease.

18F-Fluorodeoxyglucose Positron Emission Tomography Computed Tomography (PET/CT) for the diagnosis of prosthetic valve infective endocarditis (PVIE): A prospective multicenter study

18 F-FDG PET/CT has been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines, but the value of this new diagnostic algorithm has never been prospectively assessed. To assess the value of the new ESC criteria including PET/CT in prosthetic valve infective endocarditis (PVIE). Secondary objectives: to determine the reproducibility of PET/CT and to assess its ability to predict embolic events. Between 2014 and 2017, 175 patients with suspected PVIE were prospectively included in 3 French centers. After exclusion of patients with uninterpretable or not feasible PET/CT, 115 patients were finally included, including 91 definite IE and 24 rejected IE, as defined by a Consensus of Endocarditis Team after 3-month follow-up as Gold Standard. Nuclear data were blindly analyzed by two independent nuclear medicine physicians. Significant cardiac uptake by PET/CT was observed in 67 among 91 patients with definite PVIE and 6 patients with rejected IE (sensitivity 73.6%, specificity 75%, positive predictive value 91%, negative predictive value 42%). Considering cardiac uptake as a major criterion, the ESC 2015 classification increased the sensitivity of Duke criteria from 57 to 84% ( P < 0.001) but decreased its specificity from 84 to 70% ( P < 0.001). Intraobserver reproducibility of cardiac uptake evaluation was good (kappa = 0.84) but inter observer reproductibility was less satisfactory ( k = 0.63). Embolic events occurred in 31 patients (27%) and were correlated with PET/CT cardiac uptake ( P = 0.02) among others. The value of PET CT and ESC criteria is confirmed and may allow earlier diagnosis of PVIE. Reproducibility of nuclear measurements seems unsatisfactory, justifying efforts to standardize PET studies interpretation. Our study describes for the first time a positive correlation between a positive PET/Ct and occurrence of embolic events, warranting additional studies.

Physician perceptions of a multidisciplinary endocarditis team.

Infectious endocarditis is a highly morbid infection that requires coordination of care across medical and surgical specialties, often through the use of a multidisciplinary team model. Multiple studies have demonstrated that such conferences can improve clinical outcomes. However, little is known about physicians' impressions of these groups. We surveyed 126 (response rate of 30%) internal medicine, infectious diseases, cardiology, and cardiac surgery providers 1year after the implementation of an endocarditis team at the University of Michigan. Ninety-eight percent of physicians felt that the endocarditis team improved communication between specialties. Additionally, over 85% of respondents agreed that the group influenced diagnostic evaluation, reduced management errors, increased access to surgery, and decreased in-hospital mortality for endocarditis patients. These results suggest that multidisciplinary endocarditis teams are valued by physicians as a tool to improve patient care and serve an important role in increasing communication between providers.

Contemporary Surgery in Infective Endocarditis

Infective endocarditis is an uncommon disease but still carries high morbidity and mortality. The management of the patient with infective endocarditis changed over the last years with improvement of diagnostic tools and early aggressive medical and surgical treatment. The multidisciplinary approach is an accepted standard of practice and approximately 40-50% of patients discussed in endocarditis teams undergoes surgery. Timing of surgery remains a debated issue, while complexity of surgery remains a characteristic of this pathology. Although isolated native valve endocarditis remains associated with acceptable morbidity and mortality, the same still high in the setting of multiple valve surgery and prosthetic infections.

Multimodality Imaging in Infective Endocarditis: An Imaging Team Within the Endocarditis Team.

Infective endocarditis (IE) is a complex disease with cardiac involvement and multiorgan complications. Its prognosis depends on prompt diagnosis that leads to an aggressive therapeutic management combining antibiotic therapy and early cardiac surgery when indicated. However, IE diagnosis always poses a challenge, and echocardiography remains diagnostically imperfect in cases of prosthetic valve IE or cardiac implantable electronic device infection. In recent years, other imaging modalities (computed tomography, magnetic resonance imaging, nuclear imaging) have experienced significant technical improvements, and their application to the detection of cardiac and extracardiac IE-related lesions seems to be a strategic way forward in the management of patients with suspected IE. However, the scientific evidence in the literature remains limited; current guidelines address the use of the multimodality imaging in the field of IE with caution; the incremental value of each technique and their combinations is debated; and their use varies across countries. Despite these limitations, healthcare providers and surgeons should be aware of the possibilities offered by the multimodal imaging approach when appropriate. Here, we emphasize the value of a multidisciplinary heart valve team, the endocarditis team, underlining the importance of cardiac and extracardiac imaging experts in playing a key role in informing the diagnosis and management of patients with IE. Illustrative cases, critical appraisal of contemporary data, and conceptual and practical suggestions for clinicians that may help to improve the prognosis of patients with IE are provided in this review article.

The value of an "Endocarditis Team".

Establishment of the Heart Team concept in the field of cardiovascular medicine has resulted in quality improvement in the management of heart valve disease and heart failure. Similarly, the concept of an Endocarditis Team would be important in improving outcomes in patients with infective endocarditis (IE), given it is an uncommon clinical entity with general practitioners and low-volume centers lacking sufficient experience in its management. A multidisciplinary approach can substantially reduce the still unacceptably high morbidity and mortality in patients with IE, as it allows early diagnosis and appropriate comprehensive management. Decision-making within the Endocarditis Team must follow a standard protocol that is based on current clinical guidelines for the management of IE. If surgery is indicated, it is best performed sooner than later in most instances. Communication between referring hospitals and reference centers with an established Endocarditis Team must be smooth and definite protocols for transfer to experienced endocarditis centers with surgical facilities is essential. Follow-up and outpatient care following hospital discharge is crucial due to the possibility of residual infection and risk of development of recurrent endocarditis or heart failure, particularly within the first 2 years. Patient and health-care provider education is the mainstay for the accurate implementation of the Endocarditis Team concept. The following Keynote Lecture offers an overview of the current literature supporting the multidisciplinary management of IE and addresses multiple aspects related to the Endocarditis Team, highlighting its importance and necessity for the comprehensive treatment of this complex disease.

203. Correlating Cardiac PET Results with Intra-Operative Findings in Infectious Endocarditis

BackgroundCare for patients with infectious endocarditis is complicated by delays in diagnosis and relatively low sensitivity of existing diagnostic algorithms, particularly the Duke Criteria. In recent years, cardiac positron emission tomography (PET) has been identified as a useful tool in detecting occult endocardial infections. Multiple prospective studies have demonstrated that when incorporated with conventional imaging modalities cardiac PET can improve the sensitivity of the Duke Criteria by 27–38 percent. These studies used as their gold standard for diagnosis the consensus opinion of an endocarditis team and were characterized by a relatively low percentage of patients who underwent surgery. We reviewed 4 years of surgically managed IE cases at a tertiary care center where cardiac PET was used to aid diagnosis.MethodsBetween July 1, 2014 and December 31, 2018 we retrospectively reviewed 68 surgically managed cases of endocarditis. Cases were identified using ICD-9 and ICD-10 codes of patients who underwent surgical valve replacement for endocarditis as well as all patients who had cardiac PET scans to rule out endocarditis. Variables including PET results, operative findings, valve culture, pathology and PCR testing were recorded.Results14 patients were identified who underwent cardiac PET prior to their surgical intervention. 9 cases were classified as possible endocarditis by Duke Criteria and 10 involved prosthetic valves. 12/14 scans were interpreted as suggestive of or consistent with endocarditis. Twelve positive PETs were associated with either operative findings of infection and/or positive PCR testing on the excised valve (positive predictive value: 100%). The 2 patients with negative scans were found to have noninfectious vegetations intra-operatively, negative valve cultures and negative pathology.ConclusionCardiac PET correlates closely with intra-operative findings in patients with endocarditis. In patients with suspected endocarditis it may help guide surgical decision making. Cardiac PET should be considered for addition to the Modified Duke’s Criteria similar to the European Society of Cardiology guidelines. Disclosures All authors: No reported disclosures.

P3664Infective endocarditis after transcatheter aortic valve implantation, a comparison with endocarditis occurring in surgical aortic prosthesis and native aortic valve patients

Abstract Background Infective endocarditis is rare but serious. Epidemiology is well known in standard population and surgical valve patients (Pts). The recent development of Transcatheter Aortic Valve Implantation (TAVI) raises new questions about endocarditis in this population. Purpose The aim of this study was to assess outcomes of endocarditis in TAVI Pts and to compare the results to surgical aortic valve (SV) owners and native aortic valve (NV) patients. Methods We included all patients hospitalized in our institution and presenting with endocarditis after TAVI between 2012 and 2018. We compared these patients to those discussed within the “endocarditis team” and presenting with endocarditis located on SV or on NV. Results A total of 34 TAVI Pts were included and compared to a population of 45 SV and 68 NV Pts. TAVI Pts were older (83.1±1.1 yrs, vs 73.3±1.7 and 66.0±1.7, respectively; p&lt;0.001) and had a higher Charlson score (6.2±0.4, vs 5.6±0.4 and 4.1±0.3; p&lt;0.001). TAVI Pts underwent more frequently invasive procedures during the 6 months prior to the diagnosis of endocarditis (38.2%, vs 11.4 and 8.8%; p&lt;0.001). They had less incidence of a new valvular murmur (0%, vs 28.9 and 33.8%; p=0.001) and less heart failure symptoms (26.5%, vs 28.9 and 33.8%; p=0.007). Clinical complications were similar between the 3 groups and mortality was high and comparable at 1 year (29.2%, vs 36.4 and 29.7% p=0.730). However, TAVI Pts were more frequently re-hospitalized (41.2% vs 26.7% and 16.2%, p=0.02) and were treated less invasively (surgery or pacemaker extraction in 14.7% vs 35.6% and 42.6%, p=0.019). Only one TAVI Pt needed surgical aortic valve replacement. Conclusion Despite more frequent comorbidities, TAVI patients affected by infective endocarditis have the same mortality during the first year after diagnosis compared to SV and NV patients but are more often rehospitalized.

P3667Diagnostic value of cardiac CT scan in patients with suspected infective endocarditis

Abstract Background Infective endocarditis (IE) is a severe disease requiring early diagnosis and treatment. Although echocardiography (ECHO) is the key diagnostic method, CT-scan (CT) has recently been added as a new ESC diagnostic criterion. However, published data are scarce and included few patients Purpose To assess the additional value of CT over ECHO for the diagnosis of IE Methods Between 2014 and 2017, 246 pts with suspected IE underwent both ECHO and CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 222 IE were confirmed (112 native [NVE] and 110 prosthetic [PVE]) and 24 were rejected. The primary end-point was the comparison between ECHO and cardiac CT (CCT) findings. The secondary end-point was the change in diagnostic criteria sensitivity and specificity associated with the addition of CT results. Results 1. Among the 110 cases of definite PVE, – Vegetations were found in 49 (44%) pts by ECHO and 45 (40%) by CCT (agreement in 71 [64%] pts). – Periannular lesions were found in 33 (30%) pts by ECHO and 46 (41%) by CCT (agreement in 86 [77%] pts). – CCT found a new cardiac lesion missed by ECHO in 10 (9%) pts. 2. Among the 112 cases of definite NVE, – Vegetations were found in 84 (76%) pts by ECHO and 90 (81%) by CCT (agreement in 84 [76%] pts). – Periannular lesions were found in 34 (30%) pts by ECHO and 29 (26%) by CCT (agreement in 58 [52%] pts). – CCT found a new cardiac lesion missed by ECHO in 3 (3%) pts. 3. Including CT findings as major and minor criteria increased the sensitivity of Duke criteria from 60 to 70% in 124 suspected PVE, and from 73 to 80% in 122 suspected NVE, without significant decrease in specificity. Conclusions 1. This study is the largest prospective study assessing the value of CT in the diagnosis of IE. 2. Adding CT findings significantly increases the sensitivity of Duke criteria, both in NVE and PVE. 3. Our results support the use of ESC criteria including CT rather than Duke criteria.

P3669Impact of the endocarditis team on management strategies and mortality: the Dutch experience

Abstract Background Infective endocarditis (IE) was associated with poor survival. In 2015, the European Society of Cardiology (ESC) introduced the multidisciplinary IE team to improve diagnostics, treatment and outcome in patients with IE. Purpose This study evaluated the clinical implementation of the IE team in the Netherlands. Methods Retrospective cohort of all IE patients diagnosed between 2012–2016 in a tertiary single center. Clinical characteristics, data on imaging techniques, surgical procedures, IE-related complications and all-cause mortality were collected. Differences before and after installation of the IE team in 2015 were analyzed. Results Overall, 257 IE patients were included with a minimal follow-up of 1 year. No significant differences in baseline characteristics or imaging method were observed. The annual incidence of IE gradually increased over time from 36 cases in 2012 to 50 cases in 2016. This was caused by an increase in native IE cases. No difference in mortality was observed before and after 2015 (22% vs. 26%, P=0.43). After 2015, a reduction in hospitalization duration was observed (37 vs. 32 days; P=0.09) and median time to surgery had significantly decreased (18 vs. 8 days; P=0.01). Although an increase in congestive heart failure and valvulair abscess were observed a downtrend in acute renal failure (25% vs. 16%, P=0.08) was observed. Multivariate analysis demonstrated that age, COPD, diminished LV function and surgery were important predictors for mortality but not the IE team. Conclusion(s) The introduction of a multidisciplinary IE team led to earlier surgical intervention and was associated with a reduction in hospital duration but not an important predictor for mortality. These results are important in view of designing novel clinical trials.

333018F-Fluorodeoxyglucose Positron Emission Tomography Computed Tomography (PET/CT) for the diagnosis of prosthetic valve infective endocarditis (PVIE): a prospective multicenter study

Abstract Background and objectives 18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines, but the value of this new diagnostic algorithm has never been prospectively assessed. Purposes 1. Primary objective: to assess the value of the new ESC criteria including 18F-FDG PET/CT in prosthetic valve infective endocarditis (PVIE). 2. Secondary objectives: to determine the reproducibility of 18F-FDG PET/CT; to assess its ability to predict embolic events. Methods Between 2014 and 2017, 175 patients with suspected PVIE were prospectively included in 3 French centers. After exclusion of patients with uninterpretable or not feasible PET/CT,115 patients were finally included in the analysis, including 91 definite IE and 24 rejected IE, as defined by an expert Consensus of Endocarditis Team after 3-month follow-up as Gold Standard Nuclear data were blindly analyzed by two independent nuclear medicine physicians. Patients follow-up was scheduled at one and three months after hospitalization Results Significant cardiac uptake by PET/CT (major criterion) was observed in 67 among 91 patients with definite PVIE and 6 patients with rejected IE (sensitivity 73.6%, specificity 75%, positive predictive value 91%, negative predictive value 42%). Considering cardiac uptake as a major criterion, the ESC 2015 classification increased the sensitivity of Duke criteria from 57 to 84% (p&lt;0.001) but decreased its specificity from 84 to 70% (p&lt;0.001). Intraobserver reproducibility of cardiac uptake evaluation was good (kappa = 0.84) but inter observer reproductibility was less satisfactory (kappa = 0.63). Embolic events occurred in 31 patients (27%) and were correlated with vegetation size by ECHO (p&lt;0.001), Staphylococcus infection (p=0.003), and PET/CT cardiac uptake (p=0.02). Conclusion 1. the value of PET CT and ESC criteria is confirmed and may allow earlier diagnosis of PVIE 2. PET CT is associated with an increased risk of false positive results probably related to the technical improvements 3. Reproducibility of nuclear measurements seems unsatisfactory, justifying efforts to standardize PET studies interpretation 4. Our study describes for the first time a positive correlation between a positive PET/Ct and occurrence of embolic events, warranting additional studies.

Impact of Setting up an "Endocarditis Team" on the Management of Infective Endocarditis.

BackgroundInfective endocarditis (IE) remains a severe disease with a high mortality rate. Therefore, guidelines encourage the setup of a multidisciplinary group in reference centers. The present study evaluated the impact of this “Endocarditis Team” (ET).MethodsWe conducted a monocentric observational study at Strasbourg University Hospital, Strasbourg, France, between 2012 and 2017. The primary end point was in-hospital mortality. Secondary end points were 6-month and 1-year mortality, surgery rate, time to surgical procedure, duration of effective antibiotic therapy, length of in-hospital stay, and sequelae. We also assessed predictors of in-hospital mortality.ResultsWe analyzed 391 episodes of IE. In the post-ET period, there was a nonsignificant decrease in in-hospital mortality (20.3% vs 14.7%, respectively; P = .27) and sequelae, along with a significant reduction in time to surgery (16.4 vs 10.3 days, respectively; P = .049), duration of antibiotic therapy (55.2 vs 47.2 days, respectively; P < .001), and length of in-hospital stay (40.6 vs 31.9 days, respectively; P < .01). In a multivariate analysis, the post-ET period was positively associated with survival (odds ratio, 0.45; 95% confidence interval, 0.20–0.96; P = .048).ConclusionsThis multidisciplinary approach exerted a positive impact on the management of IE and should be considered in all hospitals managing IE.

Management of elderly patients with infective endocarditis

Abstract -The Elderl-IE study demonstrates IE’s high mortality in the elderly and its long-term effects on survivors, who experience significant deterioration in functional capacity. -The Elderl-IE study shows that old people with IE are treated differently than other patients. -A geriatrician should serve on the endocarditis team for patients over 80 years old. -We need more clinical trials assessing this population and the impact of multidisciplinary and individualized approaches on its mortality and quality of life and on clinical decision-making and cost outcomes.

Practical implementation of the Endocarditis Team in 'functional' reference centres: the Italian hospital network experience and recommendations of the Italian Society of Echocardiography and Cardiovascular Imaging.

: The 2015 European Society of Cardiology (ESC) guidelines for the management of infective endocarditis recommend the use of a multidisciplinary team in the care of patients with infective endocarditis. A standardized collaborative approach should be implemented in centres with immediate access to different imaging techniques, cardiac surgery and health professionals from several specialties. This position paper has been produced by the Task Force for Management of Infective Endocarditis of Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) with the aim of providing recommendations for the implementation of the Endocarditis Team within the Italian hospital network. On the basis of the Italian hospital network with many cardiology facilities encompassing a total of 405 intensive cardiac care units (ICCUs) across the country, 224 (3.68 per million inhabitants) of which have on-site 24-h PCI capability, but with relatively few centres equipped with cardiac surgery and nuclear medicine, in the present article, the SIECVI Task Force for Management of Infective Endocarditis develops the idea of a network where 'functional' reference centres act as a link with the periphery and with 'structural' reference centres. A number of minimum characteristics are provided for these 'functional' reference centres. Outcome and cost analysis of implementing an Endocarditis Team with functional referral is expected to be derived from ongoing Italian and European registries.

Mitochondrial DNA depletion and clinical presentations

Transcatheter aortic valve replacement (TAVR) is a paradigm shift for the management of severe symptomatic aortic stenosis. Infective endocarditis is a dreaded complication, which may potentially occur with TAVR, in a similar fashion to surgical aortic valve prostheses. TAVR infective endocarditis (TAVR-IE) may often be under recognized; therefore, it may be associated with higher morbidity and mortality. Here, we describe the difficulties faced with the diagnosis of TAVR-IE, and elucidate the microbiological profiles, various diagnostic strategies, and management options. Diagnosis of TAVR-IE is challenging, with potentially a lower yield on echocardiography. There is an expanding body of literature on the roles of advanced cardiac imaging techniques such as multidetector cardiac computed tomography (MDCT), Fluoro Deoxy Glucose Positron Emission Tomography (FDG-PET) and labeled leukocyte scintigraphy. Management of these patients should occur in a tertiary care hospital, by a dedicated multi-disciplinary heart valve infective endocarditis team, with the availability for advanced cardiac interventional and surgical procedures. Finally, we analyze the gaps in guidelines for management of prosthetic valve endocarditis in TAVR patients.