Evidence Of Infective Endocarditis Research Articles

1985. Infective Endocarditis in Enterococcus faecalis Bloodstream Infection: Prevalence, Risk Factors, and Patient Outcomes

Abstract Background A substantial proportion of gram-positive infective endocarditis (IE) is caused by Enterococcus species, which renders significant mortality risk. Recent European studies have attempted to identify clinical variables beyond Duke’s criteria and develop risk assessment tools. This study aimed to evaluate the prevalence of IE in our patient population with E. faecalis bloodstream infection (BSI), risk factors predictive of IE, and clinical outcomes. Methods This retrospective cohort study included adult, hospitalized patients with E. faecalis BSI in 1 tertiary and 3 community Michigan hospitals from January 1, 2018 through December 31, 2020. The primary objective was evaluation of comorbidities, clinical variables, and a previously validated NOVA (N-number of positive blood cultures, O-origin unknown, V-valvular heart disease, A-auscultation of cardiac murmur) scoring system for their association with IE using bivariate analysis and logistic regression. The secondary aim was to describe the mortality and readmissions rates with E. faecalis BSI and IE. Results We identified 167 patients with E. faecalis BSI, 65% were female, and the mean age was 71.6 (standard deviation +/- 14.8). Echocardiography was done in 68.2% of patients. There was evidence of IE in 11.9% of cases. The origin of infection was community acquired in 93.4%, an unknown source in 5.4%, and monomicrobial infections in 73.6% of patients. The comorbidities of valvular heart disease (50% with IE vs. 20.4% without IE, p=0.01) and a cardiac implantable electronic device (CIED) (35% with IE vs. 11.5% without IE, p=0.01) were associated with IE. Community acquired origin, an unknown source of infection, and NOVA scores were not associated with IE status. Patients with a CIED were more likely to have IE, with an odds ratio of 3.45 (95% confidence interval 1.06 to 11.17; p=0.04). The 30- and 60-day mortality rates were 16.7% and 19.7% with E. faecalis BSI. The 30- and 60-day readmission rates were 19.1% and 28.1%. Mortality and readmission rates did not differ among patients based on IE status. Conclusion This study revealed a significant IE prevalence of 11.9% in patients with E. faecalis BSI. Of the many previously identified risk factors for IE, patients with valvular heart disease and a CIED had the greatest risk for IE. Disclosures All Authors: No reported disclosures.

Abstract 15302: Successful Transesophageal Echocardiograms in Two Patients With Esophagectomy

Clinical Presentation: Case 1: A 74-year-old man was admitted to the ICU with altered mental status and shortness of breath. The patient had a history of esophageal adenocarcinoma and underwent an Ivor-Lewis esophagectomy 5 months prior. Blood cultures grew candida glabrata and the patient was started on an antifungal medication. A transthoracic echocardiogram was done without evidence of infective endocarditis. A transesophageal echocardiogram (TEE) was requested for higher quality imaging of the valves. Case 2: A 57-year-old man with a history of esophageal cancer with an esophagectomy done 4 years prior and atrial fibrillation (AF) presented for recurrence of AF. The patient had been maintained on apixaban and metoprolol but developed melena as well as reoccurrence of AF. An AF ablation was performed and a left atrial ablation appendage closure with a WATCHMAN device was planned for 6 weeks later. A TEE was requested intraoperatively for device guidance. Imaging Findings: In both cases, CT scans of the chest and abdomen within the last 4 months were reviewed to ensure patency of the esophagogastric anastomosis. In case 1, the TEE was performed with our standard scope without complication and showed no gross vegetations or abnormalities. In case 2, the TEE was performed with our standard scope without difficulty and showed a 20 mm x 21 mm x 20 mm left atrial appendage without thrombus. The WATCHMAN device was deployed successfully. Summary and Discussion Points: In our two patient cases, we were able to successfully perform TEE without complication in the setting of prior esophagectomy. Prior esophagectomy has traditionally been considered a barrier for TEE which can lead to limited evaluation and treatment of patients with esophagectomies where a TEE is required. In our cases, we consulted the patients’ surgeons who performed the esophagectomies and analyzed the CT images prior to performing the procedures to ensure the safety and feasibility of performing the TEE.

Vertebral osteomyelitis caused by the novel pathogen Cutibacterium modestum: a case report

BackgroundCutibacterium modestum is one of the five species of the genus Cutibacterium. While C. acnes has been reported as an important pathogen in bone and joint infections, the clinical characteristics of C. modestum infections remain unclear. Moreover, thus far, there has been no clinical case report regarding C. modestum infections.Case presentationAn 82-year-old man with a history of repeated trigger point injections for lumbago at the L4 level presented with fever and an exacerbation of lumbago. Physical examination indicated knocking pain at the L4–L5 levels; magnetic resonance imaging showed irregular bone destruction of the L4 vertebral body, and low T1 and high T2 intensity lesions at the L4–L5 intervertebral disc. Two sets of blood cultures (two aerobic and two anaerobic) were performed. Intravenous cefazolin was administered, considering the common pathogens of vertebral osteomyelitis, such as Staphylococcus aureus. The patient’s condition did not improve; thereafter, anaerobic culture bottles revealed Gram-positive rods on day 11 of incubation. There was no evidence of infective endocarditis upon transthoracic echocardiography. Needle aspiration from the L4–L5 intervertebral disc was performed on day 13 that also showed the presence of Gram-positive rods. The patient was diagnosed with vertebral osteomyelitis caused by C. modestum using a combination of characteristic peak analysis with matrix-assisted laser desorption ionization (MALDI), microbial biochemistry examinations, and 16S rRNA gene sequencing from the blood and pus cultures. He was successfully treated with alternative intravenous ampicillin, followed by oral amoxicillin for 10 weeks, according to the tests for ampicillin susceptibility, with a minimum inhibitory concentration of 0.016 μg/mL using E-test® under aerobic conditions.ConclusionsCutibacterium modestum is a microorganism that is difficult to identify. A combination of characteristic peaks with MALDI, appropriate microbial biochemical examinations, and 16S rRNA gene sequencing may serve as an efficient guide for the identification of C. modestum.

Clinical and Echocardiographic Characteristics of Bartonella Infective Endocarditis: An 8-Year Single-Centre Experience in the United States

Infective endocarditis due to Bartonella species is rare. The clinical and echocardiographic characteristics are not well defined. We aimed to investigate the clinical and echocardiographic findings of Bartonella endocarditis in the contemporary era. The infective endocarditis (IE) registry and echocardiographic database at our institution were retrospectively analysed to evaluate the clinical and echocardiographic features of Bartonella endocarditis. Between January 2008 and December 2015, there were 11 patients with Bartonella IE (0.84% among a total of 1,308 cases of definite IE): median age 54 (30-69) years, all male, 9 Caucasian, 10 had a history of cat exposure, 10 had a pre-existing valvulopathy including 6 patients with a prosthetic valve with prosthesis age range between 3 to 5 years and 1 patient with implantable cardioverter defibrillator (ICD). Bartonella henselae was responsible for all the cases. Echocardiographic evidence of IE was found in 6 of 11 patients on transthoracic echocardiography (TTE), and 6 of 8 on transoesophageal echocardiography (TEE). Bartonella IE was associated with significant valvular destruction and dysfunction on echocardiography. Nine (9) patients were managed surgically with excellent outcomes, including two patients who failed initial medical therapy. Two (2) patients who were managed medically had progression of valvular dysfunction. At a median follow-up of 6 months, there were no deaths attributable to IE or other cardiovascular causes. In a contemporary single-centre cohort in the United States, Bartonella IE remains rare, but should be considered when pathogen could not be identified in patients with suspected IE, especially those with prosthetic valves or bicuspid aortic valve (BAV). The vast majority of patients with Bartonella IE were managed surgically with excellent outcomes.

Dysgonomonas capnocytophagoides Bacteremia in a Patient With Stage IV Colon Adenocarcinoma

Dysgonomonas capnocytophagoides bacteremia is a rare clinical entity described in only five case reports. Difficulties in the identification and intrinsic multidrug resistance (MDR) of the organism make diagnosis and treatment challenging. We present a case of D. capnocytophagoides bacteremia which highlights the diagnostic and treatment challenges posed by this organism. The case also contributes to the nascent understanding of the clinical profile of patients with D. capnocytophagoides infection and the antimicrobial susceptibility of the organism.A 56-year-old male with advanced colon adenocarcinoma on palliative fluorouracil, leucovorin, and irinotecan (FOLFIRI) presented with abdominal pain. He had been discharged recently following an ICU admission for neutropenic fever with diarrhea and polymicrobial bacteremia resulting in sepsis. Diarrhea resolved during hospitalization. Mediport was retained, surveillance blood cultures remained negative, and he completed 14 days of levofloxacin. Upon readmission for abdominal pain, vital signs were normal and neutropenia had resolved. A Gram-negative rod grew from blood cultures drawn peripherally and from the port with no differential time-to-positivity. Multiple testing platforms were used in an attempt to identify the organism, to include the VERIGENE® Gram-negative blood culture test, matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry, VITEK ® 2 GN ID, and the Thermo Scientific™ RapID™ NH System (Thermo Scientific, Waltham, MA). Test results from all platforms were either inconclusive or contradictory in their identification of the organism, making the determination of appropriate treatment difficult. Given inconsistent results on multiple testing platforms, the isolate was sent for whole genome sequencing (WGS). Additional workup performed during the hospitalization included a diagnostic paracentesis without evidence of spontaneous bacterial peritonitis, transesophageal echocardiogram without evidence of infective endocarditis, and dental evaluation without evidence of the infectious source. Abdominal CT showed nonspecific terminal ileitis. He was treated for presumed HACEK bacteremia and was transitioned from piperacillin-tazobactam to ceftriaxone to complete a two-week course at hospital discharge. He also received a seven-day course of doxycycline for concomitant, mild lower extremity cellulitis which resolved during hospitalization. Ultimately, antimicrobial susceptibility testing which resulted following discharge was not consistent with the HACEK organism. Testing demonstrated resistance to multiple antimicrobials including ceftriaxone, as well as susceptibility to trimethoprim-sulfamethoxazole (TMP/SMX). WGS ultimately identified the organism as D. capnocytophagoides. Despite ceftriaxone resistance, he reported feeling well at follow-up with negative surveillance blood cultures.This patient shares several features with the few patients previously identified with D. capnocytophagoides bacteremia, including malignancy, recent neutropenia, and presumed gastrointestinal source. As in the small number of prior reported cases, the organism was difficult to identify leading to delay in diagnosis and treatment. The case demonstrates the importance of critical thinking in the face of contradictory test results. Additionally, based on susceptibility profiles described in prior literature, we suspect doxycycline treated his bacteremia.

Abstract P692: This is Your Brain on Drugs: The Burden and Severity of Stroke Related to Substance Use and Infective Endocarditis

Background: Substance abuse is a major health crisis in the US, with approximately 20 million people suffering from substance use disorders (SUD). The rate of opioid-related overdose deaths in Kentucky has climbrf from 1.3 per 100,000 persons in 1999 to a staggering 23.6 in 2016. SUD is a risk factor for infectious endocarditis (IE), an important cause of stroke in young patients. We previously reported that SUD in stroke is associated with poorer admission NIH stroke scales and longer lengths of stay (LOS) compared to patients without SUD. Objective: To describe the burden of stroke due to endocarditis in a regional population within Kentucky, and to compare outcomes of stroke in patients with SUD with or without evidence of IE. Methods: This is a single center, retrospective chart review of patients with SUD and stroke. Subjects included adults age > 18 years, who received the diagnosis of acute stroke, and were identified as an illicit drug user based on either urine drug testing or provided history in the medical record, admitted between October 2015 and May 2019. Data elements collected included length of stay (LOS), admission/discharge NIH stroke scale scores, drug use history, laboratory data, discharge modified Rankin Scores, intracerebral hemorrhage (ICH) scores, and discharge status. Results: We identified 197 (M=157, 74.6%) SUD/IE-, and 116 (M=81, 69.8%) SUD/IE+ stroke cases. SUD+/IE+ cases were younger with a mean age of 36.53 +/- 8.94, as compared to SUD+/IE-, mean age of 54.94 +/-12.01 (p<0.0001). Ischemic stroke was more common than ICH in both groups. While admission NIHSS scores were similar in the two groups, SUD+/IE+ patients had longer lengths of stay (29.60 +/-25.73 days vs. 11.65 +/-16.95, p<0.0001), and experienced greater mortality, with 38 deaths (32.8% SUD+/IE+) as compared to 20 (10.2%) in the SUD+/IE- group, p<0.0001. An additional 16 (13.8%) patients IE+ were discharged to hospice, compared to 8 (4.1%) in the IE- group, p=0.003. Conclusion: Within our regional population, there is a high burden of SUD-related infective endocarditis and stroke, which is associated with poorer outcomes and increased mortality. Further study is warranted to examine the socioeconomic factors influencing SUD in our population to reduce overall disease burden.

P4.45: Infective Endocarditis as a complication of central venous catheters used for Home Parenteral Nutrition: experience from a national Intestinal Failure Centre

Introduction:, The management of intestinal failure (IF) requires the safe and sustained delivery of parenteral nutrition (PN) via long-term central venous catheters (CVCs). Infective Endocarditis (IE) is a recognised complication of indwelling CVCs in a number of medical conditions, for example, the incidence of IE was 483 per 100 000 person-years in haemodialysis patients, while it was 6.5 per 100 000 person-years in the general US population. Indeed, recent ESPEN guidelines on the management of acute (type 2) and chronic (type 3) IF highlight IE as a potential complication. However, there are no published data on the incidence and outcomes of IE in patients with IF. Methods: This is an observational study conducted on all patients with type 2 or 3 IF admitted to a national IF Unit between January 2010 and December 2017. Patients with transthoracic(TTE) and/or transoesophageal(TOE) echocardiography evidence of IE were identified from a prospectively maintained IF database and hospital coded procedures. The diagnosis of IE was based upon Modified Duke’s Criteria, with positive blood cultures, together with a characteristic vegetation appearance on echocardiography, in combination with expert cardiology review. Details of organisms, heart valves involved and antibiotics prescribed were extracted from the patient notes, together with appropriate clinical outcomes. Results: 332 of 432 patients with indwelling CVCs admitted during the study period underwent a total of 534 echocardiograms. 513 TTE and 21TOE were performed. 2 patients were diagnosed with IE both involving native aortic valves and both visible on TTE and TOE. One patient (diagnosed with Enterococcus faecalis IE) had type 2 IF at admission from a referring hospital for ongoing treatment for IE with persistent pyrexia, splinter haemorrhages and regurgitant murmur; clinical symptoms resolved with IV Amoxicillin and Gentamicin but valve replacement was required due to severe Aortic Regurgitation. The second patient (Coagulase-negative Staphylococcus with type 3 IF) was admitted with a CRBSI, low grade pyrexia and intermittent rigors and treated with IV vancomycin and currently remains under cardiology follow up pending potential valve replacement. Conclusions: CVC-associated IE is a very rare complication of CVCs implanted for types 2 and 3 IF. However, as noted in our case series, the potential morbidity associated with this condition means that a high index of suspicion should be maintained.

Clinical features of patients with septic arthritis and echocardiographic findings of infective endocarditis.

Patients with septic arthritis (SA) often undergo echocardiographic evaluation to identify concomitant infective endocarditis (IE). The purpose of this study is to identify distinguishing features of patients with SA and IE by comparing them to patients with SA alone. We conducted a retrospective study of all patients 18 and older admitted to a single tertiary hospital between 1998 and 2015 with culture-positive SA. Patients were stratified by echocardiogram status and the presence of vegetations: those who had echocardiographic evaluation with no evidence of infective endocarditis (ECHO + IE-) or with a vegetation present (ECHO + IE+) and those who had no echocardiographic evaluation (ECHO-). Demographic data, clinical characteristics, microbiology data, treatment strategies, and patient outcomes were recorded and compared. We identified 513 patients with SA. Transthoracic echocardiogram and/or transesophageal echocardiogram were performed in 263 patients (51.2%) and demonstrated evidence for IE in 19 patients (3.7%). While most demographic features, comorbidities, and clinical characteristics did not differ significantly between those with and without IE, those with IE had higher rates of sepsis and septic shock. In addition, patients with SA and IE had higher rates of positive blood cultures and Methicillin-sensitive staphylococcus aureus (MSSA) infection when compared to those with SA without IE. Patients with IE had higher rates of intensive care unit admission and increased 30-day mortality. IE is uncommon among patients with SA. Echocardiography may be overutilized and may be more useful among patients presenting with sepsis, shock, or positive blood cultures, especially when MSSA is isolated.

Recurrent mitral paravalvular leak: benefits of leak site repair compared to re-replacement.

Mitral paravalvular leak (PVL) recurrence after surgical correction has not been well demonstrated. The aims of this study were to evaluate the long-term results of surgical mitral PVL correction, including recurrent PVL, and to elucidate the factors - including surgical technique - that affect the risk of recurrent PVL. Eighty-six patients who underwent surgical treatment for mitral PVL were enrolled in this study. Thirty-six patients underwent leak site repair (MVP group), and 50 patients underwent re-replacement (MVR group). Leak site repair was the preferred method and was performed whenever possible. The mean follow-up duration was 58.6±44.1 months (0.1-156.5 months). Operative mortality occurred in 7 patients (8.1%). There were no significant differences in operative mortality or postoperative complications between the groups. Overall survival rates at 5 and 10 years were 67.9% and 48.3%, respectively, without intergroup differences. Recurrent PVL without any evidence of infective endocarditis was found in 25 patients (29.1%). Five- and 10-year PVL-free rates were 69.9% and 18.3%, respectively. The mortality rate of reoperation for recurrent PVL was 35.2% (6/17). The risk factors of recurrent PVL were the MVR group (hazard ratio: 2.865, 95% CI: 1.077-7.619) and presence of extensive dehiscence (>25% of annulus: 2.861, 95% CI: 1.163-7.038). Recurrent PVL was not infrequent after surgical correction of mitral PVL, and reoperation may be a high-risk procedure. Leak site repair, if it could be performed, would be a good surgical option for mitral PVL because re-replacement was a risk factor for recurrence of PVL.

Comparative Sensitivity of Transthoracic and Transesophageal Echocardiography in Diagnosis of Infective Endocarditis Among Veterans With Staphylococcus aureus Bacteremia.

Echocardiography is fundamental for diagnosing infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB), but whether all such patients require transesophageal echocardiography (TEE) is controversial. We identified SAB cases between February 2008 and April 2012. We compared sensitivity and specificity of transthoracic echocardiography (TTE) and TEE for evidence of IE, and we determined impacts of IE risk factors and TTE image quality on comparative sensitivities of TTE and TEE and their impact on clinical decision making. Of 215 evaluable SAB cases, 193 (90%) had TTE and 130 (60%) had TEE. In 119 cases with both tests, IE was diagnosed in 29 (24%), for whom endocardial involvement was evident in 25 (86%) by TEE, vs only 6 (21%) by TTE (P < .001). Transesophageal echocardiography was more sensitive than TTE regardless of risk factors. Even among the 66 cases with adequate or better quality TTE images, sensitivity was only 4 of 17 (24%) for TTE, vs 16 of 17 (94%) for TEE (P < .001). Among 130 patients with TEE, the TEE results, alone or with TTE results, influenced treatment duration in 56 (43%) cases and led to valve surgery in at least 4 (6%). It is notable that, despite vigorous efforts to obtain both tests routinely, TEE was not done in 86 cases (40%) for various reasons, including pathophysiological contraindications (14%), patient refusal or other patient-related factors (16%), and provider declination or system issues (10%). Patients with SAB should undergo TEE when possible to detect evidence for IE, especially if the results might affect management.

Optimising the use of transoesophageal echocardiography in diagnosing suspected infective endocarditis

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

A Case of Pyogenic Spondylitis after Surgery for Oral Floor Cancer

We report the case of a patient who developed pyogenic spondylitis after surgery for oral floor cancer. This 85-year-old man was evaluated at our hospital for a mass in the left floor of the mouth. Oral floor cancer (T2N0M0) was diagnosed. Surgical resection of the tumor was performed twice. On postoperative day 14, he developed sudden neck pain, followed by fever the next day and a gradual decrease in blood pressure. Septic shock was diagnosed, and echocardiography was performed, but no evidence of infective endocarditis was found. Findings on neck magnetic resonance imaging suggested pyogenic spondylitis, and ultimately pyogenic spondylitis causing septic shock was diagnosed. In patients with a compromised immune system after surgery who develop neck pain and fever, the possibility of pyogenic spondylitis as a complication should be kept in mind.

Infectious endocarditis detected by PET/CT in a patient with a prosthetic knee infection: Case report and review of the literature

We report a case illustrating the potential use of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (PET/CT) for the diagnosis of infective endocarditis (IE) in an 84-y-old woman who had a history of chronic left knee osteitis and a mitral cardiac valve bioprosthesis replacement and a pacemaker. She developed a polymicrobial knee infection 15 days after her total knee replacement. Transoesophageal echocardiography showed a new mitral regurgitation, but no vegetation or abscess. PET/CT showed hypermetabolic hyperactivity around the mitral cardiac valve prosthesis and the intracardiac pacemaker leads. We found 17 case reports and 2 case series of IE in which PET/CT showed encouraging results for the detection of IE. PET/CT may be used in patients with a suspicion of IE who do not have echocardiographic evidence of IE. It may also be useful for identifying the portal of entry of an infection and for identifying secondary foci (mycotic aneurysm).

Prioritizing echocardiography in Staphylococcus aureus bacteraemia

Infective endocarditis (IE) is a severe complication in Staphylococcus aureus bacteraemia (SAB) and recent guidelines from the BSAC recommend all patients undergo echocardiography. We assessed the use of echocardiography at a major tertiary referral centre and sought to identify those patients most likely to have positive findings. We retrospectively evaluated all cases of SAB at Oxford University Hospitals NHS Trust between September 2006 and August 2011. Three-hundred-and-six out of 668 patients with SAB underwent cardiac imaging on average 9.8 ± 1.3 days from the first culture. Thirty-one patients (10.1%) had echocardiographic evidence of IE. Risk factors for observing evidence of IE on scanning included the presence of prosthetic heart valves (32% versus 4%, P < 0.001) or cardiac rhythm management (CRM) devices (16% versus 3%, P < 0.004). On excluding patients with prosthetic valves or CRM devices from the analysis, no patient with a line-related bacteraemia and only one patient (an intravenous drug user) with no/mild regurgitation on transthoracic echocardiography had echo evidence of IE. We propose that the use of scarce echocardiography resources could be prioritized. Patients with prosthetic heart valves or a CRM device should receive early cardiological input and transoesophageal echocardiography. In patients with a clearly defined line-related bacteraemia who do not have a prosthetic valve or CRM device or clinical features of IE, response to treatment could be closely monitored and imaging deferred. Patients without a line-related infection or prosthetic valve/device could receive a transthoracic echocardiogram as a screening tool.

A tetrad of bicuspid aortic valve association: A single-stage repair

We report a 27 years old male who presented with a combination of both congenital and acquired cardiac defects. This syndrome complex includes congenital bicuspid aortic valve, Seller's grade II aortic regurgitation, juxta- subclavian coarctation, stenosis of ostium of left subclavian artery and ruptured sinus of Valsalva aneurysm without any evidence of infective endocarditis. This type of constellation is extremely rare. Neither coarctation of aorta with left subclavian artery stenosis nor the rupture of sinus Valsalva had a favorable pathology for percutaneus intervention. Taking account into morbidity associated with repeated surgery and anesthesia patient underwent a single stage surgical repair of both the defects by two surgical incisions. The approaches include median sternotomy for rupture of sinus of Valsalva and lateral thoracotomy for coarctation with left subclavian artery stenosis. The surgery was uneventful. After three months follow up echocardiography showed mild residual gradient across the repaired coarctation segment, mild aortic regurgitation and no residual left to right shunt. This patient is under follow up. This is an extremely rare case of single stage successful repair of coarctation and rupture of sinus of Valsalva associated with congenital bicuspid aortic valve.

Prevalence of infective endocarditis in patients with Staphylococcus aureus bacteraemia: the value of screening with echocardiography

Staphylococcus aureus infective endocarditis (IE) is a critical medical condition associated with a high morbidity and mortality. In the present study, we prospectively evaluated the importance of screening with echocardiography in an unselected S. aureus bacteraemia (SAB) population. From 1 January 2009 to 31 August 2010, a total of 244 patients with SAB at six Danish hospitals underwent screening echocardiography. The inclusion rate was 73% of all eligible patients (n= 336), and 53 of the 244 included patients (22%; 95% CI: 17-27%) were diagnosed with definite IE. In patients with native heart valves the prevalence was 19% (95% CI: 14-25%) compared with 38% (95% CI: 20-55%) in patients with prosthetic heart valves and/or cardiac rhythm management devices (P= 0.02). No difference was found between Main Regional Hospitals and Tertiary Cardiac Hospitals, 20 vs. 23%, respectively (NS). The prevalence of IE in high-risk patients with one or more predisposing condition or clinical evidence of IE were significantly higher compared with low-risk patients with no additional risk factors (38 vs. 5%; P < 0.001). IE was associated with a higher 6 months mortality, 14(26%) vs. 28(15%) in SAB patients without IE, respectively (P < 0.05). SAB patients carry a high risk for development of IE, which is associated with a worse prognosis compared with uncomplicated SAB. The presenting symptoms and clinical findings associated with IE are often non-specific and echocardiography should always be considered as part of the initial evaluation of SAB patients.

Judicious use of transthoracic echocardiography in infective endocarditis screening

Patients with a very low probability of infective endocarditis (IE) do not benefit from transthoracic echocardiography (TTE). Because the term 'very low probability' has not yet been defined, the present prospective study sought to identify the population with a 'very low probability'. TTE was performed between July 2005 and October 2006 in consecutive patients clinically suspected of having IE. Clinical parameters suggestive of IE and presence of infectious focus were recorded. Twenty-four (15.5%) of 155 patients studied had positive findings on TTE. Significant positive predictors were embolic events, intravenous drug use, the presence of a prosthetic valve, positive blood cultures and immunological phenomena. The significant negative predictor was confirmed infection sites other than endocardium. Sixty-three (40.6%) of 155 patients without positive predictors were found to have no vegetation. Thus, the collective absence of these predictors indicated a zero probability of TTE showing evidence of IE. A significant negative predictor was a definite etiology of infection other than IE. Only one in 76 patients was diagnosed with both IE and infection at another site. The absence of positive predictors or the presence of a negative predictor indicate a near-zero probability of IE being detected by TTE. Use of clinical parameters may avoid up to 41% of unnecessary TTE examinations, increasing the likelihood that such a diagnosis will be correct.

ASDIN Original Investigations: Myocardial Abscess and Fatal Cardiac Arrhythmia in a Hemodialysis Patient with an Arterio‐venous Fistula Infection

AbstractMyocardial abscess formation is a life‐threatening complication that is frequently but not exclusively associated with infective endocarditis. To our knowledge there are only two case reports of myocardial abscess formation in hemodialysis patients. Only one of these reports describes a myocardial abscess of bacterial etiology secondary to an infected intravascular hemodialysis catheter. Furthermore, there are no reports of bacterial myocardial abscess occurring in a hemodialysis patient with an infected arteriovenous fistula. Myocardial abscess can manifest in a variety of clinical scenarios ranging from an asymptomatic state to a catastrophic myocardial wall rupture. In the case described, the myocardial abscess lead to a rapidly progressive course consisting of recurrent cardiac arrhythmias that were ultimately fatal. Our case involved the formation of a myocardial abscess in the presence of a methicillin‐resistant Staphylococcus aureus bacteremia without any evidence of infective endocarditis. We report this case to call attention to the possibility of bacterial myocardial abscess occurring with infection of an arteriovenous fistula in a hemodialysis patient, which can manifest as recurrent severe cardiac arrhythmias refractory to medical therapy.

Early Surgery in Patients with Infective Endocarditis: A Propensity Score Analysis

An accurate assessment of the predictors of long-term mortality in patients with infective endocarditis is not possible using retrospective data because of inherent treatment biases and predictable imbalances in the distribution of prognostic factors. Largely because of these limitations, the role of surgery in long-term survival has not been adequately studied. Data were collected prospectively from 426 patients with infective endocarditis. Variables associated with surgery in patients who did not have intracardiac devices who had left-side-associated valvular infections were determined using multivariable analysis. Propensity scores were then assigned to each patient based on the likelihood of undergoing surgery. Using individual propensity scores, 51 patients who received medical and surgical treatment were matched with 51 patients who received medical treatment only. The following factors were statistically associated with surgical therapy: age, transfer from an outside hospital, evidence of infective endocarditis on physical examination, the presence of infection with staphylococci, congestive heart failure, intracardiac abscess, and undergoing hemodialysis without a chronic catheter. After adjusting for surgical selection bias by propensity score matching, regression analysis of the matched cohorts revealed that surgery was associated with decreased mortality (hazard ratio, 0.27; 95% confidence interval, 0.13-0.55). A history of diabetes mellitus (hazard ratio, 4.81; 95% confidence interval, 2.41-9.62), the presence of chronic intravenous catheters at the beginning of the episode (hazard ratio, 2.65; 95% confidence interval, 1.31-5.33), and paravalvular complications (hazard ratio, 2.16; 95% confidence interval, 1.06-4.44) were independently associated with increased mortality. Differences between clinical characteristics of patients with infective endocarditis who receive medical therapy versus patients who receive surgical and medical therapy are paramount. After controlling for inherent treatment selection bias and imbalances in prognostic factors using propensity score methodology, risk factors associated with increased long-term mortality included diabetes mellitus, the presence of a chronic catheter at the onset of infection, and paravalvular complications. In contrast, surgical therapy was associated with a significant long-term survival benefit.

Double valve replacement for acute spontaneous left chordal rupture secondary to chronic aortic incompetence

A 54 years old male with undiagnosed chronic calcific degenerative aortic valve incompetence presented with acute left anterior chordae tendinae rupture resulting in severe left heart failure and cardiogenic shock. He was successfully treated with emergency double valve replacement using mechanical valves. The pathogenesis of acute rupture of the anterior chordae tendinae, without any evidence of infective endocarditis or ischemic heart disease seems to have been attrition of the subvalvular mitral apparatus by the chronic regurgitant jet of aortic incompetence with chronic volume overload. We review the literature with specific focus on the occurrence of this unusual event.