First Episode Of Infective Endocarditis Research Articles

876 VENTRICULAR SEPTAL DEFECT AND RIGHT-SIDED INFECTIVE ENDOCARDITIS

Abstract Introduction Right-sided infective endocarditis (IE) accounts for 5-10% of IE cases; it is most frequently associated with intravenous drug abuse but can also be observed in patients with cardiac implantable electronic devices, central venous catheters or congenital heart diseases. Case report A 34-year-old female, with unrepaired perimembranous ventricular septal defect (VSD) and right ventricle and tricuspid valve (TV) IE with lung septic embolism treated conservatively with antibiotic therapy 16 years ago, was admitted to our hospital for persistent fever and cough unsuccessfully treated with empiric antibiotic therapy. She denied intravenous drug abuse and recent surgical or dental procedures. Blood cultures resulted positive for multi sensitive Staphylococcus lugdunensis, so antibiotic therapy with Oxacillin and Gentamicin was started. Suspecting IE, transesophageal echo (TEE) was performed and showed, inside VSD, a small fluctuating vegetation and, along the right side of the interventricular septum, next to the VSD, a voluminous hypomobile vegetation; septal and anterolateral TV leaflets appeared thickened and infiltrated by vegetations floating into the right atrium; at color-Doppler moderate TV regurgitation. A whole-body computed tomography showed right lung abscess and right kidney septic infarct. Endocarditis Team, considering hemodynamic stability and inflammatory biomarkers and surveillance blood cultures negativization, decided for medical therapy with echocardiographic follow-up. TEE performed at the end of antibiotic therapy demonstrated complete disappearance of the above described vegetations and surgical VSD closure was scheduled. Discussion Patients with unoperated small VSDs and without volume overload signs usually remain asymptomatic and do not require surgery; nevertheless, a small percentage of them develops problems later in life and IE represents one of the main concerns. Even if unrepaired VSD is associated with increased risk of IE compared with the general population, antibiotic prophylaxis is still recommended only for high-risk patients undergoing at-risk dental procedures, while non-specific oral and cutaneous hygiene measures should always be applied. Latest ESC Guidelines for the management of adult congenital heart disease state that in patients with no significant left to right shunt, but a history of repeated episodes of IE, VSD closure should be considered (IIa, C); it's still matter of debate whether closure should be performed after the first episode of IE. Conclusion IE should always be suspected in patients with VSD and persistent fever. Optimal oral and skin hygiene are effective prevention measures, while prophylactic antibiotic therapy is indicated only in selected cases. Surgery should be considered after repeated episodes of IE.

TRICUSPID VALVE INFECTIVE ENDOCARDITIS REQUIRING VALVE REPLACEMENT THREE TIMES IN AN IV DRUG USER

TRICUSPID VALVE INFECTIVE ENDOCARDITIS REQUIRING VALVE REPLACEMENT THREE TIMES IN AN IV DRUG USER

Five-Year Cardiovascular Outcomes after Infective Endocarditis in Patients with versus without Drug Use History.

Background: Disparities in treatment and outcomes of infective endocarditis (IE) between people who use drugs (PWUD) and non-PWUD have been reported, but long-term data on cardiovascular and cerebrovascular outcomes are limited. We aim to compare 5-year rates of mortality, cardiovascular and cerebrovascular events after IE between PWUD and non-PWUD. Methods: Using data from the TriNetX Research Network, we examined 5-year cumulative incidence of mortality, myocardial infarction, heart failure, atrial fibrillation/flutter, ventricular tachyarrhythmias, ischemic stroke, and intracranial hemorrhage in 7132 PWUD and 7132 propensity score-matched non-PWUD patients after a first episode of IE. We used the Kaplan–Meier estimate for incidence and Cox proportional hazards models to estimate relative risk. Results: Matched PWUD were 41 ± 12 years old; 52.2% men; 70.4% White, 19.8% Black, and 8.0% Hispanic. PWUD had higher mortality vs. non-PWUD after 1 year (1–3 year: 9.2% vs. 7.5%, p = 0.032; and 3–5-year: 7.3% vs. 5.1%, p = 0.020), which was largely driven by higher mortality among female patients. PWUD also had higher rates of myocardial infarction (10.0% vs. 7.0%, p < 0.001), heart failure (19.3% vs. 15.2%, p = 0.002), ischemic stroke (8.3% vs. 6.3%, p = 0.001), and intracranial hemorrhage (4.1% vs. 2.8%, p = 0.009) compared to non-PWUD. Among surgically treated PWUD, interventions on the tricuspid valve were more common; however, rates of all outcomes were comparable to non-PWUD. Conclusions: PWUD had higher 5-year incidence of cardiovascular and cerebrovascular events after IE compared to non-PWUD patients. Prospective investigation into the causes of these disparities and potential harm reduction efforts are needed.

Different drugs, different sides: injection use of opioids alone, and not stimulants alone, predisposes to right-sided endocarditis

ObjectivesMany studies suggest that infective endocarditis (IE) in people who inject drugs is predominantly right sided, while other studies suggest left sided disease; few have differentiated by class of drug...

Clinical profile and outcome of recurrent infective endocarditis

AimsPurpose of this study is to compare the clinical course and outcome of patients with recurrent versus first-episode infective endocarditis (IE).MethodsPatients with recurrent and first-episode IE enrolled in the EUROpean...

56. Long-Term Cardiovascular Outcomes After Drug-Related vs Non-Drug-Related Infective Endocarditis

BackgroundDrug use-related infective endocarditis (IE) has nearly doubled in the past two decades in the United States, largely due to the current opioid crisis. Although there are robust data on surgical outcomes for people who use drugs (PWUD) vs. non-PWUD patients after an initial encounter for IE, long-term comparative data on post-IE outcomes are relatively sparse.MethodsUsing data from the TriNetX electronic health records network, we identified (1) a cohort of patients 16 to 64 years old who had a first encounter for IE (captured with ICD-10 codes I33, I38, or I39) and history of drug use (captured with ICD-10 codes F11, F13-F16, F18, F19, O99.32, or T40) preceding the IE episode and (2) a propensity score-matched cohort of patients age 16-64 who had a first episode of IE and no documented drug use. We compared the post-IE incidence of (1) mortality; (2) ischemic stroke; (3) intracranial hemorrhage; (4) myocardial infarction; (5) heart failure; and (6) sudden cardiac death (cardiac arrest or ventricular fibrillation or tachycardia) between the 2 cohorts over a 5-year follow up period. We matched the cohorts for demographic data and clinically relevant medical history. We used Kaplan-Meier estimates and Cox models to compare incidence. ResultsWe identified 6,578 PWUD patients and 6,578 matched non-PWUD patients 16-64 years old with a first episode of IE. The baseline characteristics are summarized in Table 1. Standardized mean differences of characteristics were generally < 0.1, indicating adequate matching. The 5-year Kaplan-Meier rates of outcomes of interest are summarized in Table 2. Mortality did not differ between cohorts. However, the incidence of ischemic stroke and intracranial hemorrhage was consistently higher among PWUD throughout the 5-year follow-up. Rates of myocardial infarction were also higher among PWUD; however, the difference was more pronounced later during follow-up. Rates of heart failure and sudden cardiac death did not differ. ConclusionCardiovascular events after IE were common among both PWUD and non-PWUD patients over a 5-year follow-up period. However, rates of ischemic and hemorrhagic stroke were consistently higher among PWUD. Further investigation is needed to elucidate the sources of elevated stroke risk among PWUD and identify targets for intervention. Disclosures All Authors: No reported disclosures

Value of polymerase chain reaction in etiological diagnostic of infectiove endocarditis

Abstract Introduction Identification of a causative agent in patients with infective endocarditis (IE) is crucial for diagnostic and prescribing etiotropic therapy which defines positive outcome of a disease. High rate of a culture negative IE and inaccurate results of traditional microbiological methods raise a concern. So the methods of etiological diagnostics in IE are in need of development, particularly introduction of polymerase chain reaction (PCR) method might be helpful. Aim Modernisation of the algorithm of IE etiological diagnostic by introducing PCR Materials and methods The study included 85 cases of IE [first episode of IE (n=79), recurrence/relapse (n=6)] verified by DUKE criteria 2009, 2015, hospitalized in Moscow primary hospital from 2012 to 2017. All patient had venous blood investigated both with microbiological method and with broadrange and specific PCR. Following microorganisms' DNA were assessed by PCR: Staphylococcus spp. (MRCoNS, S. aureus and others), Streptococcus spp. (S. agalactiae, S. pyogenes and others), Enterococcus spp. (E. faecium, E. faecalis and others), Enterobacteriaceae, Klebsiella spp. (K. pneumoniae and others), E. coli, Proteus spp., A. baumanii, P. aeruginosa, Fungi (C. albicans, C. glabrata, Aspergillus spp. and others). Results Median age was 55.48 years (95% confidence interval (CI) 51.16–59.8), males 67.9%. History of cardiovascular diseases was in 54 (68.35%), diabetes mellitus in 18 (22.78%), hepatitis B and/or C in 31 (39.2%), intravenous drug dependency in 27 (34.18%), chronic kidney disease in 38 (48.1%), median Charlson comorbidity index was 5.44 (95% CI 4.52–6.37). Left-side IE was in 50 (63.29%), right-side IE – in 23 (29.12%), left-right-side IE in 6 (7.59%). Secondary IE was in 53 patients (62.3%). Embolic events were diagnosed in 27 cases (34.18%), in-hospital mortality – in 22 (27.8%). Microbiological method identified etiological agent in 55 of 85 cases (61.2%), featuring Staphylococcus aureus (n=23), Staphylococcus CoNS (n=6), Escherichia coli (n=1), Acinetobacter spp. (n=2), Streptococcus spp. (n=2), Enterococcus spp. (n=8), Klebsiella pneumoniae (n=2), Gemella haemolysans (n=2), several causative agents (n=6). Additional PCR testing identified etiology in 14 of 33 (42.2%) featuring Staphylococcus spp. (n=6), Enterococcus spp. (n=3), Streptococcus spp. (n=1), Aspergillus sp. (n=1) Pasteurella multocida (n=1), Enterococcus spp. + Staphylococcus spp. (n=1), Staphylococcus spp.+ A. baumanii + E. coli (n=1). PCR method identified 6 fals-positive results of microbilogical investigation [S. epidermidis (n=2), G. haemolysans, Acinetobacter spp., E. faecalis, K. pneumoniae], that are most probably due to preanalytical sample contamination Conclusions Introduction of PCR into the algorithm of IE etiological diagnostic increased validity of laboratory findings on 23.5%. True culture negative IE was present in 19 of 85 patients. Rate of mortality and complications in IE remains high. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Peoples' Friendship University of Russia (RUDN), Moscow, Russia

Injection drug use infective endocarditis: clinical features and therapeutic challanges

Abstract Introduction Injection drug use (IDU) is a known risk factor for infective endocarditis (IE) and is associated with frequent recurrences, but its prognostic impact is still debated. Moreover, the potential futility of surgery in this population is an unsolved matter. Purpose We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of injection drug use IE (IDUIE). Method We retrospectively included in the analysis 454 consecutive episodes of definite active IE admitted in a single surgical centre from January 2012 to December 2020; 14 out of them where a subsequent infective episode of the same patient. Results IDUIE cases were 63 (13.8%), without significant proportional differences over time. IDUIE patients were significantly younger (43.95±10.12 vs 67.84±13.33, p 0.00) and presented fewer comorbidities (p&amp;lt;0.001). They were admitted with a first episode of IE only in 60.3% of cases vs 92.8% of non-IDU (p&amp;lt;0.001). Embolism was present at admission in a higher percentage (60.3 vs 38.4%, p&amp;lt;0.001). IDUIE was more frequently associated with spondylodiscitis (15.9 vs 7.4%, p=0.026). The infection was less frequently left-sided than in non-IDU patients (57.1 vs 97.2%, p&amp;lt;0.001) and was more often polimicrobic (12.7 vs 4.9%, p=0.015). Most patients were positive for Staphylococcus aureus (54.0 vs 12.8%, p&amp;lt;0.001), while Streptococci were significantly less frequent in patients with IDUIE (11 vs 25%, p=0.015). The proportion of patients undergoing surgery was similar among the two groups (85.5 vs 78.8%, NS). IDUIE patients treated medically for absence of surgical indication had a better survival than patients undergoing surgery for complicated IE (p&amp;lt;0.001). IDUIE was associated with a higher proportion of relapse during follow-up (28.3 vs 3.3%, p&amp;lt;0.001). It was not associated with higher mortality (Figure 1) but was an independent predictor of mortality in multivariable analysis including age (HR per unit 1.048, 95% CI 1.038–1.063, p=0.00) and drug abuse (HR 3.2, 95% CI 1.8–5.6, p=0.00; Figure 2). Among IDUIE patients, we did not find predictors of futility of surgery, not even multiple relapses. Conclusions IDUIE represents a considerable proportion of overall cases of IE, mainly affecting young people. Staphylococcus aureus is the most common microbiologic agent. IDUIE is not associated with higher mortality but drug abuse is an independent predictor of mortality. Considering that patient with uncomplicated IE treated medically have a better prognosis, we should reserve surgery to patients with a strict indication for it. On the other hand, since there are no predictors of futility of surgery, all patients with a complicated IE should undergo surgery without delay. The main determinant of prognosis in these patients is not IE but drug abuse itself. For this reason, increased focus on addiction treatment following hospital discharge is mandatory to improve long term prognosis. Funding Acknowledgement Type of funding sources: None.

Risk factors and outcomes of early acute kidney injury in infective endocarditis: A retrospective cohort study

ObjectivesThe incidence of acute kidney injury (AKI) in infective endocarditis (IE), its risk factors and consequences on patient and renal survival remain debated. MethodsPatients hospitalized for a first episode of IE (possible or definite according to modified Duke criteria) between 2013 and 2016 were included. The primary endpoint was to determine risk factors for early AKI (E-AKI) during the first week of management of IE. ResultsA total of 276 patients were included: 220 (79.7%) had definite IE and 56 (20.3%) had possible IE. E-AKI occurred in 150 patients (53%). IE due to Staphylococcus aureus (OR 3.41; 95% CI 1.83–6.39; p<0.01), history of diabetes (OR 2.34; 95% CI 1.25–4.37; p<0.01), peripheral arterial disease (OR 2.59; 95% CI 1.07–6.23; p<0.05), immunological manifestations (OR 3.11; 95% CI 1.31–7.39; p=0.01), and use of norepinephrine (OR 3.44; 95% CI 1.72–7.02; p<0.01) were associated with E-AKI. In subgroup analysis, infectious disease consultation was associated with a lower risk of AKI at day 7 (OR 0.41; 95% CI 0.16–0.88; p=0.04). E-AKI was associated with 1-year mortality (OR 1.65; 95% CI 1.03–2.64; p=0.04) and chronic kidney disease progression (OR 2.23; 95% CI 1.30–3.82; p<0.01). ConclusionsE-AKI is common in IE and often associated with non-modifiable variables. Multidisciplinary management should be mandatory, and awareness of AKI diagnosis and etiological explorations should be raised.

170. Predictors of Recurrent Infective Endocarditis in Intravenous Drug Users

BackgroundCaring for hospitalized patients with infective endocarditis (IE) can be challenging due to the nature of the disease and its complications, underlying medical and psychiatric problems, socioeconomic status and environmental factors.Some of these patients develop recurrent IE after the first episode treated. On-going intravenous (IV) drug use after hospital discharge is the highest predictive factor for recurrent IE. Besides IV drug use, there are limited data of other contributing factors to recurrent IE. Those factors may be modifiable during the first hospitalization to reduce the incidence of recurrent IE.MethodsA retrospective cohort study was conducted at a large tertiary acute care medical center in Tampa, Florida. All consecutive patients with IE with history of IV drug use from January, 2011 to December, 2017 were included. Basic demographic information, co-morbidities (diabetes, hypertension, chronic lung and kidney diseases, HIV, Hepatitis B and C status, coronary artery diseases), valves involved, length of stay, complications at their first IE episode such as septic shock and stroke were included. Groups were identified based on the first episode, first recurrence and second or more recurrences of IE.ResultsA total of 106 patients were identified based on the inclusion criteria. The association between the type of valve infection (right side and left side) and IE recurrence was found to be statistically significant. (P = 0.003). Right side valves are prone to have recurrent IE episodes. People with recurrent IE were more likely to have septic shock (P = 0.02) and requiring intensive care unit (ICU) admissions (P < 0.001) during their first episode There was no statistically significant difference between other demographic information and recurrent endocarditis as well as other parameters such as organisms or type of substance used. (Table 1)ConclusionRight-sided IE and presence of septic shock during their first episode of IE may be the predictors for recurrent IE. Interventions including closer follow-up, more aggressive septic shock recognition and management, socioeconomic assessment in addition to substance abuse treatments after discharge should be considered to prevent recurrent IE. Disclosures All authors: No reported disclosures.

Contemporary epidemiology and outcomes in recurrent infective endocarditis

ObjectiveRecurrent infective endocarditis (IE) is a major complication of patients surviving a first episode of IE. This study sought to analyse the current state of recurrent IE in a large...

1021. Repeat Infective Endocarditis (rIE) in Persons Who Inject Drugs (PWID)

BackgroundInjection drug use (IDU) is a major risk factor for infective endocarditis (IE). Rates of IE have recently increased in the US concurrent with the opioid crisis. Although IDU-related IE is well described, few data exist on repeat IE (rIE) in persons who inject drugs (PWID).MethodsPatients ≥18 years old seen at Wake Forest Baptist Medical Center from 2004–2017 with an ICD-9 or -10 diagnosis of IE who met Duke criteria for IE and who self-reported IDU in the 3 months prior to admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after the diagnosis of the first episode, was then reviewed.ResultsOf the 94 PWID with IE, 22 (23.4%) experienced rIE (19 re-infections, three relapses). All patients were Caucasian, 50% were male, and 68.2% lived in rural areas; the median age was 30. All 22 patients resumed IDU after their first episode of IE. The mean duration from completion of antibiotics for the prior IE episode to admission with rIE was 257.5 days; the episode of rIE occurred within 1 year in 17 patients (77.3%). On repeat admission, those with rIE had a Pitt bacteremia score of 3.0 and an APACHE II score of 13.1. Fever and bacteremia persisted for an average of 5.6 days and 2.6 days, respectively. S. aureus was the cause of rIE in 54.5% of patients and the tricuspid valve (TV) was involved in 77.3% of cases. Valve surgery occurred in 22.7% of patients. Mean length of stay was 25.3 days and mean duration of antibiotic therapy was 32.1 days. Seven patients (31.8%) died during the rIE hospitalization and another died within 12 months after discharge resulting in a 1-year mortality of 36.3%. Compared with their first episode of IE, rIE patients had higher admission Pitt bacteremia (3.0 vs. 1.5, P = 0.07) and APACHE II scores (13.1 vs. 9.5, P = 0.18), fewer S. aureus infections (54.5% vs. 95.4%, P = 0.01), similar TV involvement (77.3% vs. 72.7%, P = 1), and less frequent surgery (22.7% vs. 59.1%, P = 0.06).ConclusionrIE is common in PWID with most episodes occurring within 1 year of the initial episode. Reinfection is more frequent than relapse. The microbiology of rIE is more varied than first episode IE in PWID with S. aureus being less frequently isolated. Illness severity is high, hospitalizations are prolonged, and 1-year mortality is significant. More effective strategies for preventing rIE in PWID are needed.Disclosures J. Peacock, Pfizer: Shareholder, Owns common stock in Pfizer which was inherited and held in a trust.

Clinical Characteristics and Factors Associated With Mortality in First-Episode Infective Endocarditis Among Persons Who Inject Drugs

Persons who inject drugs (PWID) represent a distinct demographic of patients with infective endocarditis. Many centers do not perform valvular surgery on these patients owing to concerns about poor outcomes. Addiction services are underused in hospitals. To compare clinical characteristics in first-episode infective endocarditis in PWID who are surgically vs medically managed and to identify variables associated with mortality. This case series studied PWID treated for a first episode of infective endocarditis between April 1, 2007, and March 30, 2016. Participants were adult patients (aged ≥18 years) admitted to any of 3 hospitals in London, Ontario, Canada. Analysis occurred between July 2016 and November 2017. Survival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management. Of 370 total first-episode cases of infective endocarditis, 202 (54.6%) were in PWID. Among PWID, 105 (52%) were male, the median (interquartile range) age was 34 (28-42) years, and patients were predominantly positive for the hepatitis C virus (69.8% [141 of 202]). Right-sided infection was more common (61.4% [124 of 202]), and most infections were caused by Staphylococcus aureus (77.2% [156 of 202]). Surgery occurred in 19.3% of patients (39 of 202). The all-cause mortality rate was 33.7% (68 of 202). Adjusting for age and sex, survival analysis demonstrated that surgery was associated with lower mortality (hazard ratio [HR], 0.44; 95% CI, 0.23-0.84; P = .01), as was referral to addiction treatment (HR, 0.29; 95% CI, 0.12-0.73; P = .008). Higher mortality was associated with left-sided infection (HR, 3.26; 95% CI, 1.82-5.84; P < .001) and bilateral involvement (HR, 4.51; 95% CI, 2.01-10.1; P < .001). This study presents the demographic characteristics of first-episode infective endocarditis in PWID. Results highlight the potentially important role of addictions treatment in this population. Further study to optimize selection criteria for surgery in PWID is warranted.

Repeat Infective Endocarditis in Persons Who Inject Drugs: "Take Another Little Piece of my Heart".

BackgroundInjection drug use (IDU) is a major risk factor for infective endocarditis (IE). Few data exist on repeat IE (rIE) in persons who inject drugs (PWID).MethodsPatients ≥18 years old seen at Wake Forest Baptist Medical Center from 2004 to 2017 who met Duke criteria for IE and who self-reported IDU in the 3 months before admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after diagnosis of the first episode, was then reviewed.ResultsOf the 87 PWID who survived their first episode of IE, 22 (25.3%) experienced rIE and 77.3% had rIE within a year of the first episode. All patients who experienced rIE resumed IDU between episodes of IE. Of the patients with rIE, 54.5% had an infection caused by S. aureus and 22.7% required surgical intervention. Mortality at 1 year was 36.3%. Compared with their first IE episode, patients with rIE had fewer S. aureus infections (P = .01). Compared with PWID who experienced single-episode IE, intravenous prescription opioid use (P = .01), surgery (P < .01), tricuspid valve involvement (P = .02), and polymicrobial infection (P = .03) occurred more often during first episodes of IE in individuals who then developed rIE.ConclusionsrIE is common among IDU-related IE and confers a high 1-year mortality rate. The microbiology of rIE is varied, with S. aureus being less frequently isolated. More studies on modification of social and clinical risk factors are needed to prevent rIE.

Risk and outcomes of aortic valve endocarditis among patients with bicuspid and tricuspid aortic valves

ObjectivePatients with structural abnormalities of cardiac valves, including bicuspid aortic valve (BAV), are said to be at higher risk of infective endocarditis (IE). We sought to determine the risk of...

Infective Endocarditis After Transcatheter Pulmonary Valve Replacement Using the Melody Valve

Transcatheter (percutaneous) pulmonary valve (TPV) replacement has emerged as a viable therapy for right ventricular outflow tract conduit dysfunction. Little is known about the incidence, clinical course, and outcome of infective endocarditis (IE) after TPV implant. We reviewed combined data from 3 ongoing prospective multicenter trials to evaluate the experience with IE among patients undergoing TPV replacement using the Melody valve. Any clinical episode reported by investigators as IE with documented positive blood cultures and fever, regardless of TPV involvement, was considered IE. Cases were classified as TPV-related if there was evidence of vegetations on or new dysfunction of the TPV. The 3 trials included 311 patients followed for 687.1 patient-years (median, 2.5 years). Sixteen patients were diagnosed with IE 50 days to 4.7 years after TPV implant (median, 1.3 years), including 6 who met criteria for TPV-related IE: 3 with vegetations, 2 with TPV dysfunction, and 1 with both. The annualized rate of a first episode of IE was 2.4% per patient-year and of TPV-related IE was 0.88% per patient-year. Freedom from TPV-related IE was 97±1% 4 years after implant. All patients were treated with intravenous antibiotics, 4 had the valve explanted, and 2 received a second TPV. There was 1 sepsis-related death, 1 patient died of sudden hemoptysis, and 2 patients developed recurrent IE. Bacterial endocarditis has occurred in all 3 prospective multicenter studies of the Melody valve in North America and Europe. Most cases did not involve the TPV and responded to antibiotics. More data are necessary to understand risk factors in this population.

Infective Endocarditis in the Pediatric Patient: A 60-Year Single-Institution Review

ObjectiveTo determine the epidemiology of infective endocarditis (IE) presenting in pediatric patients during a 60-year period at our institution. Patients and MethodsIn this retrospective medical record review, we extracted demographic characteristics, diagnostic variables, and outcomes for patients less than 20 years of age diagnosed with IE from January 1, 1980, to June 30, 2011. We compared this cohort with a previously reported cohort of pediatric patients with IE from our institution diagnosed from 1950 to 1979. ResultsWe identified 47 patients (24 males; mean ± SD age at diagnosis, 12.3±5.5 years [range, 1 day to 18.9 years]) who had 53 episodes of IE. The most common isolated organisms were viridans streptococci (17 of 53 episodes [32%]) and Staphylococcus aureus (12 of 53 episodes [23%]). Of the 47 patients, 36 (77%) had congenital heart disease, 24 of whom had cardiac surgery before their first episode of IE (mean ± SD time to IE diagnosis after surgery, 4.2±3.2 years [range, 64 days to 11.3 years]). Fourteen patients (30%) required valve replacement because of valvular IE, and 16 (34%) had complications, including mycotic aneurysm, myocardial abscess, or emboli. Vegetations were identified using echocardiography in 37 of the 53 unique episodes of IE (70%). Endocarditis-related mortality occurred in 1 patient. Compared with the historical (1950-1979) cohort, there were no differences in patient demographic characteristics, history of congenital heart disease, or infecting organisms. One-year mortality was significantly lower in the modern cohort (4%) compared with the historical cohort (38%) (P<.001). ConclusionMost pediatric episodes of IE occur in patients with congenital heart disease. Mortality due to endocarditis has decreased in the modern era.

Infective Endocarditis in Patients Receiving Long-term Hemodialysis

To ascertain the predominant characteristics of patients receiving long-term dialysis who develop infective endocarditis (IE). We reviewed the records of all chronic hemodialysis patients who had IE at Mayo Clinic, Rochester, Minn, between 1983 and 1997. Twenty episodes of IE occurred in 17 patients. One patient had 3 episodes of IE, and 1 patient had 2 episodes of IE; each episode was caused by a different organism. The mean +/- SD age of our patients was 63 +/- 11 years; there were 13 males; 6 patients had diabetes mellitus; and the mean +/- SD duration of hemodialysis prior to IE was 24.2 +/- 20.5 months. This analysis included 10 episodes of IE (occurring in 9 patients) within the Mayo Clinic Dialysis System during which time 223,358 hemodialysis treatments were delivered, giving a rate of 10 IE episode per 223,336 hemodialysis treatments. Among all 20 IE episodes, there were 14 synthetic arteriovenous grafts, 4 permanent venous dialysis catheters, 2 temporary venous dialysis catheters, and 2 native arteriovenous fistulas (2 accesses in 2 patients), and access had been in place for a mean +/- SD of 15.9 +/- 18.6 months. The portal of infection was the hemodialysis access in 13 episodes of IE. The causative organisms for IE were Staphylococcus aureus in 8 cases, Enterococcus sp in 4 cases, viridans streptococcus in 3 cases, Staphylococcus epidermidis in 2 cases, and 1 case each of Streptococcus bovis, group G beta-hemolytic streptococcus, and Aspergillus sp. The mitral valve was involved in 9 cases, the aortic valve was involved in 5 cases, and the tricuspid and pulmonic valves were involved in 1 case each. Patient survival (after the first episode of IE) was 71% at 30 days; 53% at 60 days; and 35% at 1 year. Echocardiography was performed in 19 episodes of IE. The transthoracic echocardiogram was 62.5% sensitive and 40% specific for the presence of definite or probable vegetations. Univariate analysis for factors affecting 60-day survival show that presence of right-sided IE, vegetation size greater than 2.0 cm3, diagnosis of diabetes mellitus, and initial leukocyte count greater than 12.5 x 10(9)/L were poor prognostic factors. Aortic valve involvement carried a better prognosis. Infective endocarditis in hemodialysis patients is relatively infrequent but has a high mortality. Patients with synthetic intravascular dialysis angioaccess (synthetic grafts and venous catheters) are more likely to develop IE than patients with native arteriovenous fistulas. Transesophageal echocardiography is a preferred echocardiographic study for suspected cases of IE. Prolonged antibiotic therapy is needed for all patients, and close monitoring is needed for patients with right-sided IE, large vegetations, diabetes mellitus, and an elevated leukocyte count.

Long-term complications of native valve infective endocarditis in non-addicts. A 15-year follow-up study.

To describe the incidence and clinical manifestations of long-term cardiac complications of endocarditis. Cohort study. University-affiliated tertiary medical center. One hundred twelve consecutive patients, survivors from a series of 140 non-addicted patients with a first episode of infective endocarditis on native valves hospitalized from 1975 to 1990. Thirty-two patients had had valve replacement during the active phase of the infection, and the remaining 80 patients received medical treatment alone. Relapse, recurrence, need for late cardiac surgery, and cardiac mortality. Relapses occurred in three patients (2.7%) and recurrences in five patients (4.5%, incidence density at 15 years, 0.0030 per patient-year). Late cardiac surgery was needed by 47% of the patients treated medically during the active phase, and most had surgery in the first 2 years of follow-up (incidence density, 0.25 per patient-year at 2 years). Aortic valve involvement (relative risk, 2.66; 95% CI, 1.15 to 6.17) and end-diastolic diameter greater than 60 mm (relative risk, 1.04; 95% CI, 1.03 to 2.43) were associated with the need for late surgery in univariate analysis. Multiple logistic regression analysis showed aortic valve involvement to be an independent predictor of the need for late surgery (relative risk, 3.04; CI, 1.23 to 7.54). Only 2 of the 32 patients who had surgery during the active infection needed a second operation during follow-up. At the end of follow-up, the number of patients who had surgery after the onset of the infection was 86 (60% of the whole series). Cardiac death occurred in 16 patients; most deaths were sudden or postoperative and occurred in the first 2 years of follow-up (incidence density, 0.047 per patient-year at 2 years). Independent predictors of death were not found. Survival was 90% at 2 years, 88% at 5 years, 81% at 10 years, and 61% at 15 years. Survival after infective endocarditis is fair (81% probability of survival at 10 years), and the most common types of cardiac death are sudden and postoperative. Aortic valve involvement is an independent predictor of the need for late cardiac surgery. The rate of recurrences is not negligible (incidence density at 15 years, 0.0030 per patient-year).

Infective endocarditis in opiate addicts: Analysis of 80 cases studied at necropsy

Eighty opiate addicts were studied at necropsy. Fifty-nine patients had anatomic evidence of active infective endocarditis (IE); 11 had healed IE; and 10 had both. Of the 80 patients, the first episode of IE involved a single right-sided cardiac valve in 24 patients (30%); both a right- and a left-sided valve in 13 patients (16%); a single left-sided valve in 33 patients (41%); and both left-sided valves in 10 patients (13%). Of the 320 cardiac valves in the 80 patients, 103 were sites of vegetations, an average of 1.3 of the 4 valves. Of the 80 patients, the tricuspid valve was infected in 35 (44%), mitral in 34 (43%), aortic in 32 (40%) and pulmonic in 2 (3%). Of the 103 infected cardiac valves, the infection caused sufficient damage to cause dysfunction in 70 (68%): in 28 (88%) of 32 infected aortic valves; in 22 (63%) of 35 infected tricuspid valves; in 19 (56%) of the 34 infected mitral valves; and in 1 of the 2 infected pulmonic valves. Of the 80 patients, 57 (71%) had sufficient valvular damage to cause valvular dysfunction. Of the 80 patients, gross examination of the valves at necropsy indicated that the infected valve almost certainly had been anatomically normal in 65 patients (81%) and abnormal in 15 patients (19%) before the onset of IE. Of the 65 patients with previously anatomically normal valves, 86 (33%) of their 260 cardiac valves were sites of infection (average 1.3 valves/patient); of the 15 patients with infection superimposed on a previously abnormal valve, the infection in each involved previously abnormal valves (21 in the 15 patients) or 17 (28%) of their 60 cardiac valves were sites of infection (average 1.1 valve/patient). Of the 15 patients with abnormal cardiac valves before the infection, 7 had congenitally bicuspid aortic valves and 8 had diffuse fibrous thickening of the mitral valve typical of rheumatic heart disease with (6 patients) or without (2 patients) diffuse fibrous thickening of tricuspid aortic valves. Of the 80 patients, 42 (53%) died during their first episode of active IE, 17 (21%) underwent operative excision with or without valve replacement during the active IE, and in 21 patients (26%) the first episode of active IE healed. In 10 of the latter 21 patients, active IE recurred and was fatal. A total of 19 patients had cardiac valve excision with or without replacement, 17 during active IE and 2 after healing. Of the 19 patients, 5 died within 30 days of operation, 10 (56%) within a year of operation and 16 (80%) within 3 years. Of the 13 patients surviving > 30 days after valvular operation, 5 developed prosthetic or bioprosthetic endocarditis, which was fatal in each. Thus, the first episode of active IE appears to have a high mortality because the infection most often involves previously normal valves that are easily destroyed by vegetations. When the valvular vegetations are operatively excised, with or without replacement, prognosis remains poor because of the danger of prosthetic or bioprosthetic endocarditis. When the active IE is eradicated by antibiotics without operation, recurrence of IE at sites of previously healed IE is common.