Diagnosis Of IE Research Articles

Imaging in Infective Endocarditis-Current Opinions and Trends in Cardiac Computed Tomography.

Infective endocarditis is a rare disease with an increasing incidence and an unaltered high mortality rate, despite medical development. Imaging plays an integrative part in the diagnosis of infective endocarditis, with echocardiography as the initial diagnostic test. Research data in the utility of cardiac computed tomography (CCT) in the diagnostic algorithm of IE are rising, which indicates its importance in detection of IE-related lesion along with the exclusion of coronary artery disease. The latest 2023 European Society of Cardiology Guidelines in the management of IE classified CCT as class of recommendation I and level of evidence B in detection of both valvular and paravalvular lesions in native and prosthetic valve endocarditis. This review article provides a comprehensive and contemporary review of the role of CCT in the diagnosis of IE, the optimization of acquisition protocols, the morphology characteristics of IE-related lesions, the published data of the diagnostic performance of CCT in comparison to echocardiography as the state-of-art method, as well as the limitations and future possibilities.

Clinical characteristics and analysis of prognostic factors in methicillin-resistant Staphylococcus aureus endocarditis: A retrospective multicenter study in Japan

BackgroundInfective endocarditis (IE) caused by MRSA (methicillin-resistant Staphylococcus aureus) is associated with a high mortality rate. This study aimed to elucidate the characteristics of patients with MRSA-IE in Japan and identify the factors associated with prognosis. MethodsThis retrospective study included patients with a confirmed diagnosis of IE caused by MRSA, between January 2015 and April 2019. ResultsA total of 65 patients from 19 centers were included, with a mean age of 67 years and 26 % were female. Fifty percent of the patients with IE were had nosocomial infections and 25 % had prosthetic valve involvement. The most common comorbidities were hemodialysis (20 %) and diabetes (20 %). Congestive heart failure was present in 86 % of patients (NYHA class I, II: 48 %; III, IV: 38 %). The 30-day and in-hospital mortality rates were 29 % and 46 %, respectively. Multi-organ failure was the primary cause of death, accounting for 43 % of all causes of death. Prognostic factors for in-hospital mortality were age, disseminated intravascular coagulation, daptomycin and/or linezolid as initial antibiotic therapy, and surgery. Surgical treatment was associated with a lower mortality rate (odds ratio [OR], 0.026; 95 % confidence interval [CI], 0.002–0.382; p = 0.008 for 30-day mortality and OR, 0.130; 95 % CI; 0.029–0.584; p = 0.008 for in-hospital mortality). ConclusionMortality due to MRSA-IE remains high. Surgical treatment is a significant prognostic predictor of MRSA-IE.

Elucidating common pathogenic transcriptional networks in infective endocarditis and sepsis: integrated insights from biomarker discovery and single-cell RNA sequencing.

Infective Endocarditis (IE) and Sepsis are two closely related infectious diseases, yet their shared pathogenic mechanisms at the transcriptional level remain unclear. This research gap poses a barrier to the development of refined therapeutic strategies and drug innovation. This study employed a collaborative approach using both microarray data and single-cell RNA sequencing (scRNA-seq) data to identify biomarkers for IE and Sepsis. It also offered an in-depth analysis of the roles and regulatory patterns of immune cells in these diseases. We successfully identified four key biomarkers correlated with IE and Sepsis, namely CD177, IRAK3, RNASE2, and S100A12. Further investigation revealed the central role of Th1 cells, B cells, T cells, and IL-10, among other immune cells and cytokines, in the pathogenesis of these conditions. Notably, the small molecule drug Matrine exhibited potential therapeutic effects by targeting IL-10. Additionally, we discovered two Sepsis subgroups with distinct inflammatory responses and therapeutic strategies, where CD177 demonstrated significant classification value. The reliability of CD177 as a biomarker was further validated through qRT-PCR experiments. This research not only paves the way for early diagnosis and treatment of IE and Sepsis but also underscores the importance of identifying shared pathogenic mechanisms and novel therapeutic targets at the transcriptional level. Despite limitations in data volume and experimental validation, these preliminary findings add new perspectives to our understanding of these complex diseases.

Valvulitis: a new echocardiographic criterion for the diagnosis of prosthetic valve infective endocarditis

Abstract Background Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been previously described in some patients with aortic bioprosthetic valve endocarditis (PVE). This echocardiographic finding has been termed valvulitis. Objectives Our aim was to estimate the prevalence of valvulitis, to precisely describe its echocardiographic characteristics, and to determine their clinical significance in patients with aortic bioprosthetic valve endocarditis. Methods From 2011 to 2022, 388 consecutive patients with IE admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with aortic bioprosthetic valve endocarditis (n=86) were selected, and their TEE images were thoroughly evaluated by three independent cardiologists to identify all potential cases of valvulitis. The diagnosis of valvulitis was considered to be present when all three were in complete agreement. Results Prevalence of isolated valvulitis in the total cohort was 12.8%, and 20.9% of patients had valvulitis accompanying other classical echocardiographic findings of IE. A description of the main clinical and imaging findings of 11 patients with valvulitis and no other echocardiographic signs of IE is shown at the Table. Diagnosis status corresponds to the criteria for the diagnosis of IE according to the ESC 2015 IE guidelines, including 18F-FDG PET/CT. TEE long-axis and short-axis views of a patient with bioprosthetic valvulitis (homogeneous and hypoechoic thickening of the aortic leaflets) resulting in severe aortic stenosis are shown at the Figure, Panel A. At Panel B, abnormal FDG uptake (white arrow) at the prosthetic valve is seen on PET/CT scan of the same patient. At Panel C, histology of the aortic bioprosthetic leaflet of the same patient with valvulitis is presented (hematoxylin and eosin stain of the aortic leaflet; granulation tissue is well demonstrated (red bracket) covering the aortic fibrosa (red asterisk)). Moderate or severe valve stenosis was more common in those with valvulitis (81.8 vs 34.9%, p<0.001). Patients with isolated valvulitis tended to have a lower IE-related in-hospital mortality (9.1 vs 23.3%, p=0.219) and cardiac surgery was less frequently performed than in the other subjects with aortic PVE (27.3 vs 58.1%, p=0.17), but these results were not statistically significant. Conclusions Valvulitis can be the only echocardiographic finding in infected biological aortic prosthesis and needs to be recognized by imagers for early patient diagnosis. The identification of this sort of lesion is important since the clinical profile and management of these patients is different from that of patients with classical PVE.TableFigure

Performance of 18F-FDG PET/CT in the diagnosis of endocarditis

Abstract Background Infectious endocarditis (IE) remains a diagnostic challenge that requires a combination of clinical, microbiology, and imaging clues. Usefulness of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) in the diagnostic algorithms has been demonstrated. However, performances of 18F-FDG PET/CT vary greatly between studies and types of IE. 18F-FDG PET/CT may have a better sensitivity for prosthetic valve IE (PVE) than for native valve IE (NVE) or cardiac implantable electronic devices IE (CIED-IE). Purpose Define the performance of 18F-FDG PET/CT after echocardiography in the diagnosis of all types of IE in our institution. Methods This hybrid study was conducted at a university hospital from January 2014 to June 2022 (retrospective cohort: 2014-17 and prospective cohort: from 2018 onwards). Adult patients with a suspected valvular or CIED-IE were included. Realization of 18F-FDG PET/CT was left at the discretion of the treating physician or by an endocarditis-team that was established in 2018. 18F-FDG PET/CT analysis were performed nuclear medicine physicians and radiologists (when the CT was contrast-enhanced), based on visual interpretation. The final diagnosis of possible or definite IE was defined by the endocarditis team according to European Society of Cardiology 2015 modified Duke criteria. Results During the study period, 280 18F-FDG PET/CT with interpretable intracardiac results were performed for a clinical suspicion of IE in 247 patients. A final IE diagnosis was retained for 116 episodes (41%; 81 definite and 35 possible IE), among which 102 valvular (59 NVE and 44 PVE) and 20 CIED-IE. 18F-FDG PET/CT showed radiologic signs of endocarditis in 60 episodes (21%) with an overall specificity, sensitivity, positive and negative predictive values (PPV, NPV) of 97.6%, 48.3%, 93.3%, and 72.7%, respectively. This led to an overall accuracy of 77.1% and between 80 to 85% when looking at specific types of IE. Performances of 18F-FDG PET/CT for each type of IE are shown in Figure 1. Addition of 18F-FDG PET/CT to the modified Duke criteria reclassified the diagnosis in 37 cases: from possible/rejected IE to definite IE in 25 cases (21.5%) and from rejected IE to possible IE in 12 cases (10.3%) (Figure 2). Figure 2 shows a Shankey diagram of classification of episodes by clinical Duke criteria without 18F-FDG PET/CT results (left side), clinical Duke criteria with 18F-FDG PET/CT results (center) and final diagnosis retained by clinicians (right side). Conclusion Use of 18F-FDG PET/CT in a multimodal diagnostic approach led to an acceptable accuracy for all types of IE in our center. Signs of endocarditis on 18F-FDG PET/CT should be interpreted as confirmatory, while absence of sign do not efficiently rule out this diagnosis. In this cohort, 18F-FDG PET/CT helped to reclassify 15.9% of possible or rejected IE.Performance of 18F-FDG PET/CTShankey diagram of IE classification

Comparing clinical outcomes in bicuspid versus trileaflet aortic valve endocarditis

Abstract Background The incidence of bicuspid aortic valve infective endocarditis (BAV-IE) has been reported at 2% in contemporary BAV cohorts with an estimated risk of developing BAV-IE 11 times that of the general population with a trileaflet aortic valve (TAV). Purpose To characterise BAV-IE from a clinical and microbiological perspective and compare clinical outcomes with a cohort of individuals with trileaflet aortic valve infective endocarditis (TAV-IE). Methods The clinical records of all patients (>16 years old) admitted to a large tertiary referral centre in the United Kingdom between 2015 and 2022 with a definitive diagnosis of native aortic valve IE by Duke’s criteria were included. Clinical, echocardiographic and microbiological data were obtained. The primary outcomes were death or surgical aortic valve intervention during the indexed hospital admission. Secondary outcomes included the incidence of cardiac complications (e.g. aortic root abscess or fistula formation, IE affecting another valve or high degree atrioventricular block requiring temporary or permanent pacing). Extra-cardiac complications included embolic phenomena and thrombotic events. Results 83 patients were included (BAV-IE 34; TAV-IE 49). BAV-IE patients were significantly younger at presentation than TAV-IE patients (Table 1). There was no difference age-adjusted mortality rate between the two groups (mortality rate BAV-IE 0.20 (95% CI 0.08-0.54) versus TAV-IE 0.29 (95% CI 0.17-0.48). The rate of cardiac complications including aortic root abscess or fistula formation, and concomitant mitral valve endocarditis was greater in the BAV group, though not reaching statistical significance. Those in the BAV-IE group were more likely to develop at least moderate aortic regurgitation and have aortic valve intervention during the admission (70.6% (24/34) BAV-IE versus 46.9% (23/49) TAV-IE, p=0.03). Conclusion Despite an estimated prevalence of 1% in the general population, BAV accounted for 41% of all native AV IE cases at our institution. This study demonstrates that even in young, otherwise healthy individuals, BAV-IE has a poor prognosis with a high proportion developing structural complications. Age-adjusted mortality rates are similar to those with TAV-IE, who are often older with more co-morbidities. Though antibiotic prophylaxis is currently only recommended for those at the highest risk, these findings reinforce the importance of mitigating sources of infection in individuals with BAV. Prompt medical attention and treatment of suspected IE cases is of utmost importance as degeneration of a BAV and other cardiac complications, particularly aortic regurgitation, can rapidly develop.

Occult deterioration of an aortic annular abscess: how do we diagnose a pseudoaneurysm periaortic valve? A case report

BackgroundInfectious endocarditis (IE) is a disease caused by the colonization of toxic microorganisms on the endocardium of heart valves [1]. Although much progress has been made in the diagnosis and treatment of IE, its complications, such as annular abscesses [2], still have a high mortality rate. In this case, we describe a patient with infective endocarditis complicated by occult deteriorated aortic annular abscess.Case presentationA 44-year-old man was admitted due to weakness of his right limbs and unclear speech for 10 h. He had recurrent fevers for 1 month before admission. Transthoracic echocardiography showed a mix-echoic vegetation attached to the bicuspid aortic valve, moderate aortic regurgitation and a possible aortic annular abscess. Blood cultures were negative and empiric antibiotic therapy was begun. The patient did not have fever again and seem to be clinically improved. However, follow-up transesophageal echocardiography revealed a large periaortic abscess led to aortic sinus pseudoaneurysm. The patient underwent mechanical prosthetic valve replacement and annulus reconstruction successfully. Perivalvular abscess may be insidious deterioration in patients who seem to be clinically improved, which requires us to pay more attention.DiscussionOccult deterioration of an aortic annular abscess is rare and more attention should be paid. Re-evaluation of echocardiography is required even if the patient’s symptoms improve.

Infective endocarditis presenting as meningitis: a case report.

Here, the authors present a case of a 53-year-old male who presented with bacterial meningitis secondary to IE. His blood culture was positive for methicillin-sensitive staphylococcal aureus. Echocardiography findings were suggestive of endocarditis. Despite aggressive intensive care management, our patient did not survive. The isolation of Staphylococcus aureus in culture should raise a suspicion of foci being elsewhere outside the central nervous system. Treatment of complications like meningitis may require intrathecal antibiotics. The vegetation and neurological complications are often difficult to treat and require the participation of a multidisciplinary team. The diagnosis of IE in patients presenting with neurologic deficits and fever should be considered. A physician should raise a suspicion of infective foci being elsewhere outside the central nervous system if the organism isolated in culture is Staphylococcus aureus.

P483 IMPACT OF AN ENDOCARDITIS TEAM ON PROGNOSIS: PRELIMINARY RESULTS

Abstract Infective endocarditis (IE) is a life–threatening microbial infection with high mortality rate (6–50% in–hospital and 19–82% at 5–years)1.Guidelines for management of infective endocarditis underline the importance of multidisciplinary approach with an Endocarditis Team (ET) for the complexity of disease and for prognosis which depends on patients’ characteristics, microorganisms involved and local or systemic complications.ET includes specialists that define multimodality imaging approach to confirm diagnosis and to exclude local or systemic complications, discuss timing of antibiotic therapy, indication and timing of surgical treatments and follow–up. This study was a retrospective analysis based on a population of 86 patients from Infermi Hospital, Rimini, who received a diagnosis of IE from 2019 to 2021 thanks to a multidisciplinary approach. Among 86 patients, 76 (88,4%) had early–diagnosed IE and 10 (11,3%) had late–diagnosed IE.Early–diagnoses IE was defined when diagnoses occurred within 30 days from first symptoms.The aim of this study was to assess the impact of ET on timeliness of diagnosis and prognosis.Comparing the two groups, in the early–diagnosed IE we found higher rate of risk factors for endocarditis and systemic embolisation (27,6% vs. 20%), with Staphylococcus and Streptococcus as the most frequent causative pathogens (43,4% and 31,5%).More frequently the late–diagnosed IE group had mechanical prosthetic valves (20% vs 7,8%) with a higher rate of cardiac surgery (80% vs 35,5%), cardiac valves complications such as abscesses, perforations and pseudo–aneurysms (20% vs 18,4%) and a higher rate of intra–hospital mortality (40% vs 18,4%). Streptococcus and Enterococcus were most involved in the late–diagnosed group.Several trials demonstrated that presence of ET reduces 1–year mortality from 18.5% to 8.2% 2 and in–hospital mortality from 28% to 13% 3. Our preliminary study confirms the importance of ET application to improve early diagnosis (88.4%) and to reduce mortality. Bibliography:1.Kouijzer et al., Native valve, prosthetic valve, and cardiac device–related infective endocarditis: A review and update on current innovative diagnostic and therapeutic strategies(2022). 2.Botelho–Nevers et al. Dramatic reduction in infective endocarditis–related mortality with a management–based approach(2009). 3.Chirillo,F.et al. Impact of a multidisciplinary management strategy on the outcome of patients with native valve infective endocarditis(2013).

Transcatheter Aortic Valve Replacement for Aortic Valve Infective Endocarditis: A Systematic Review and Call for Action.

We aimed to systematically analyze the literature on the use of transcatheter aortic valve replacement (TAVR) to treat active aortic valve infective endocarditis (AV-IE). Surgery is declined in one-third of patients with IE who meet indications because of prohibitive surgical risk. TAVR might be an alternative for selected patients with AV-IE as a bridge-to-surgery or stand-alone therapy. PubMed/MEDLINE, Embase, and Cochrane databases were searched (2002-2022) for studies on TAVR use in active AV-IE. Of 450 identified reports, six met inclusion criteria (all men, mean age 71 ± 12years, median Society of Thoracic Surgeons (STS) score 27, EuroSCORE 56). All patients were prohibitive surgical risk candidates. Five out of six patients had severe, and one patient had moderate aortic regurgitation on presentation. Five out of six patients had prosthetic valve endocarditis after surgical valve replacement 13years before (median), and one patient had TAVR a year before hospitalization. All patients had cardiogenic shock as the indication for TAVR. Four patients received balloon-expanding, and two patients received self-expanding TAVR after a median of 19(IQR 9-25) days from diagnosis of IE. No death or myocardial infarction occurred, but one patient had a stroke within the first 30days. The median event-free time was 9 (IQR 6-14) months including no death, reinfection, relapse IE, or valve-related rehospitalization. Our review suggests that TAVR can be considered as an adjuvant therapy to medical treatment for selected patients in whom surgery is indicated for treatment of acute heart failure due to aortic valve destruction and incompetence caused by infective endocarditis, but who have a prohibitive surgical risk. Nonetheless, a well-designed prospective registry is urgently needed to investigate the outcomes of TAVR for this off-label indication. No evidence exists for using the TAVR to treat infection-related surgical indications such as uncontrolled infection or control of septic embolization.

Impact of Enterococci vs. Staphylococci Induced Infective Endocarditis after Transcatheter Aortic Valve Implantation

The two most common organisms found in infective endocarditis following transcatheter aortic valve implantation (TAVI-IE) are enterococci (EC-IE) and staphylococci (SC-IE). We aimed to compare clinical characteristics and outcomes of patients with EC-IE and SC-IE. TAVI-IE patients from 2007 to 2021 were included in this analysis. The 1-year mortality was the primary outcome measure of this retrospective multi-center analysis. Out of 163 patients, 53 (32.5%) EC-IE and 69 (42.3%) SC-IE patients were included. Subjects were comparable with regard to age, sex, and clinically relevant baseline comorbidities. Symptoms at admission were not significantly different between groups, except for a lower risk for presenting with septic shock in EC-IE than SC-IE. Treatment was performed in 78% by antibiotics alone and in 22% of patients by surgery and antibiotics, with no significant differences between groups. The rate of any complication, in particular heart failure, renal failure, and septic shock during treatment for IE, was lower in EC-IE compared with SC-IE (p < 0.05). In-hospital (EC-IE: 36% vs. SC-IE: 56%, p = 0.035) and 1-year mortality (EC-IE: 51% vs. SC-IE: 70%, p = 0.009) were significantly lower in EC-IE compared with SC-IE. EC-IE, compared with SC-IE, was associated with a lower morbidity and mortality. However, absolute numbers are high, a finding that should trigger further research in appropriate perioperative antibiotic management and improvement of early IE diagnosis in the case of clinical suspicion.

Predictors of mortality in Vietnamese patients with infective endocartis

Abstract Funding Acknowledgements Type of funding sources: None. Background Infective endocarditis (IE) has been associated with an elevated mortality rate despite major advances in diagnostic and therapeutic methods for the past decades. Purpose to evaluate predictors of in-hospital all-cause mortality in patients with IE. Methods This was a retrospective cross-sectional study among patients who were 15 years of age or older with the definite or probable diagnosis of IE according to the modified Duke criteria admitted to Cho Ray Hospital between January 1, 2015 and December 31, 2019. Patients whose medical records with insufficient data to collect were excluded from the study. The minimum sample size of the study was 99 patients. Results Of the 201 hospitalized patients with IE, 157 patients (78.1%) had definite diagnosis and 44 patients (21.9%) had probable diagnosis according to the modified Duke criteria. Men accounted for 65.2% and women accounted for 34.8%. The mean age of patients was 42.2±15.3. All-cause in-hospital mortality rate was 15.9%. Factors associated with in-hospital mortality in univariate analysis included sex, chronic kidney disease, prior heart failure, cough, Streptococci, Staphylococcus aureus, white blood cell count, estimated glomerular filtration rate, acute heart failure, septic shock, cerebral infarction, cerebral hemorrhage, and surgical treatment. Multivariate logistic regression analysis showed that five independent prognostic factors of in-hospital mortality were male gender (OR=0.33; 95% CI: 0.11–0.97; P=0.043); prior heart failure (OR=5.29; 95% CI: 1.42–19.65; P=0.013); estimated glomerular filtration rate (OR=0.98; 95% CI: 0.97–0.99; P=0.045); septic shock (OR=9.53; 95% CI: 1.76–51.76; P=0.009); and surgical treatment (OR=0.20; 95% CI: 0.05–0.75; P=0.017). Conclusions The rate of mortality in IE has remained high and its predictors should be taken into consideration to improve outcomes.

Infective endocarditis in adults with congenital heart disease: Contemporary management and related outcomes in Central and South-Eastern European region

BackgroundInfective endocarditis (IE) remains major cause of morbidity and mortality in adult congenital heart disease (ACHD). Limited data exists on ACHD with IE in Central and South-Eastern European (CESEE) countries. The aim of this study is to characterize contemporary management and assess outcomes of ACHD with IE in CESEE region. MethodsData on ACHD patients with IE from 9 tertiary centres in 9 different CESEE countries between 2015 and 2020 was included. Baseline demographics, clinical presentation, indication for surgery, outcomes, hospital and all-cause-1-year mortality were studied. ResultsA total of 295 ACHD patients (mean age 40 ± 14 years) with IE were included. Median time from symptoms onset to establishing diagnosis was 25 (11–59) days. The majority of patients (203, 68.8%) received previous empiric oral antibiotic therapy. The highest incidence of IE was observed on native and left sided valves, 194(65.8%) and 204(69.2%), respectively. More than half had a vegetation size ≥10 mm (164, 55.6%); overall 138 (46.8%) had valve complications and 119 (40.3%) had heart failure. In-hospital mortality was 26 (8.8%). ConclusionThere is clear delay in establishing IE diagnosis amongst ACHD patients in CESEE countries. Adequate diagnosis is hampered by common prescription of empiric antibiotics before establishing formal diagnosis. Hence, patients commonly present with associated complications requiring surgery. Hospital treatment and survival are, nevertheless, comparable to other Western European countries. Improved awareness and education of patients and medical profession regarding IE preventive measures, risks, signs, and symptoms are urgently needed. Empiric antibiotic prescription before blood cultures are taken must be omitted.

Unexpected septic pulmonary embolism imaging with 18-F FDG PET/CT in an infective endocarditis case: case report

BackgroundInfective endocarditis (IE) is a severe disease that is diagnosed using a combination of clinical, microbiologic, and imaging criteria (modified Duke criteria). The prognosis relies on the degree of valvular involvement and crucially the presence of systemic infectious embolism. We present an educational infective endocarditis case with images of 18-F fluoro-D-glucose positron emission tomography/computed tomography (18-F FDG PET/CT) showing hypermetabolic lesions on the prosthetic tricuspid valve and papillary muscle of right ventricle. Besides these lesions, PET/CT showed an unexpected hypermetabolic extra-cardiac focus.Case presentationA 36-year-old male patient with IE history was underwent 18-F FDG PET/CT imaging. FDG PET revealed hypermetabolic lesions on the prosthetic tricuspid valve and papillary muscle of right ventricle. Besides these lesions, PET/CT showed an unexpected hypermetabolic focus in the lower lobe of the right lung, which was consistent with septic pulmonary embolism.Conclusions18-F FDG PET/CT is a valuable, noninvasive imaging modality in diagnosis of prosthetic valve IE. It could change treatment planning since detecting extra-cardiac lesions.

Risk calculator to predict 30-day mortality in left-sided infective endocarditis. The EURO-ENDO score

Abstract Background/Introduction Infective endocarditis (IE) is associated with high in-hospital mortality, despite improvements in therapeutic strategies. Nonetheless, there is no prospective risk model to estimate IE mortality. Purpose We sought to develop and validate a calculator to predict 30-day mortality risk regarding to perform surgery or medical treatment alone in left-sided IE. Methods This is a prospective, multicenter registry that included patients between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Patients with possible or definite left-sided IE were included in the analyses. Clinical, biological, microbiological and imaging data were collected. The primary end point was 30-day mortality in patients with left-sided IE. The risk calculator was based on multivariable Cox regression models. The accuracy of the logistic regression models was assessed by discrimination and calibration using C-statistic and Hosmer-Lemeshow test. Results Among 3116 patients included, 2171 patients presented left-sided IE and 257 patients (11.8%) died during the first 30 days of IE diagnosis. After multivariable Logistic regression analysis, eleven variables were associated with 30-days mortality and were included in the calculator: previous cardiac surgery, previous stroke/TIA, creatinine &amp;gt;2 mg/dL, S. aureus infection, embolic events on admission, heart failure or cardiogenic shock, vegetation size &amp;gt;14 mm, presence of abscess, severe regurgitation, double left-sided IE and no left valve surgery. There was an excellent correlation between the predicted 30-days mortality in both models with or without performing left valve surgery (area under the receiver operator curve: 0.798 and 0.758, respectively). Moreover, calibration by Hosmer-Lemeshow were 0.085 and 0.09, respectively). Conclusion(s) Our risk score in patients with left-sided IE provides an accurate individualized estimation of 30-day mortality according to perform or not perform left-valve surgery. It allows medical professionals to determine whether submitting patients to surgery or not, and thus improve their prognosis. Funding Acknowledgement Type of funding sources: None.

Infective Endocarditis: Clinical Characteristics and Echocardiographic Findings.

PurposeInfective endocarditis (IE) remains a disease with high morbidity and mortality. The aim of this study was to determine the clinical characteristics and echocardiographic features of patients with IE.MethodsWe analyzed patients with either definitive or probable diagnosis of IE who were hospitalized in a teaching hospital in Mashhad, Iran between June 2011 and January 2020. Patients who survived were followed up by echocardiography for at least 6-month after hospital discharge.ResultsA total of 82 cases with IE were included of which 62 (75.6%) received definitive diagnosis. The mean age was 39.7 ± 18.7 years and 52 (63.4%) were male. The most common preexisting structural cardiac abnormality that predispose patients to IE were congenital heart diseases (28 %) of which bicuspid aortic valve was more common (n = 12, 14.6%), followed by ventricular septal defect (n = 9, 11%) and Tetralogy of Fallot (TOF) (n = 2, 2.4%). Three (3.6 %) cases had rheumatic heart disease and 12 (14.6 %) were injecting drug users. The most common causative pathogen was Staphylococcus aureus, detected in 7 (19.4%) cases. Follow-up echocardiography revealed right or left ventricular failure in 10 (12.1%) cases. Cardiac complications occurred in 41 (50%) cases and systemic complications in 63 (76.8%). All-cause mortality was 41.5% (n = 34) and 6 (18.1%) patients died due to cardiovascular complications.ConclusionsThe short- and long-term prognosis in IE was poor and the predictors for in-hospital and 1-year mortality were defined as heart failure and septic shock. Congenital heart disease and intravenous illicit drug using (IVDU) were the most common predisposing condition which may necessitate a revision in the IE prophylaxis recommendations.

Correlates of 90-Day Mortality Among People Who Do and Do Not Inject Drugs With Infective Endocarditis in Seattle, Washington

BackgroundInfective endocarditis (IE) remains highly morbid, but few studies have evaluated factors associated with IE mortality. We examined correlates of 90-day mortality among people who inject drugs (PWID) and people who do not inject drugs (non-PWID).MethodsWe queried the electronic medical record for cases of IE among adults ≥18 years of age at 2 academic medical centers in Seattle, Washington, from 1 January 2014 to 31 July 2019. Cases were reviewed to confirm a diagnosis of IE and drug use status. Deaths were confirmed through the Washington State death index. Descriptive statistics were used to characterize IE in PWID and non-PWID. Kaplan-Meier log-rank tests and Cox proportional hazard models were used to assess correlates of 90-day mortality.ResultsWe identified 507 patients with IE, 213 (42%) of whom were PWID. Sixteen percent of patients died within 90 days of admission, including 14% of PWID and 17% of non-PWID (P = .50). In a multivariable Cox proportional hazard model, injection drug use was associated with a higher mortality within the first 14 days of admission (adjusted hazard ratio [aHR], 2.33 [95% confidence interval {CI}, 1.16–4.65], P = .02); however, there was no association between injection drug use and mortality between 15 and 90 days of admission (aHR, 0.63 [95% CI, .31–1.30], P = .21).ConclusionsOverall 90-day mortality did not differ between PWID and non-PWID with IE, although PWID experienced a higher risk of death within 14 days of admission. These findings suggest that early IE diagnosis and treatment among PWID is critical to improving outcomes.

Infective endocarditis misdiagnosed as cANCA – associated vasculitis

A previously healthy 37-year-old man was admitted to a nephrology clinic due to the left-sided abdominal pain, petechiae and recurring hematuria. Laboratory tests revealed high levels of C-reactive protein and Antineutrophil Cytoplasmic Antibodies (cANCA). On this basis, vasculitis was suspected and prednisone in high doses was administered. After 30 days of immunosuppressive treatment, due to persistence of symptoms, the patient was referred for an ambulatory echocardiographic study, and because of the abnormal result, he was admitted to our department. On admission, the patient was clinically in good condition. However, the physical examination revealed a systolic-diastolic heart murmur. Transthoracic echocardiography demonstrated a vegetation attached to the non-coronary aortic leaflet and severe aortic insufficiency. Additionally, an abnormal, perforated, bulging of the anterior mitral leaflet was present, with severe mitral insufficiency (Figure 1). Three blood cultures were positive for Streptoccocus sanguinis. Therefore, the patient was diagnosed with IE according to the modified Duke criteria. Subsequently, the treatment was adjusted to include intravenous antibiotic therapy with vancomycin and ceftriaxone. Afterwards, the patient was qualified for the replacement of the aortic and mitral valves with mechanical valve prostheses. The procedure was uneventful and the patient was discharged home in good condition. The medical history of this patients is an outstanding example of how complex and misleading the IE diagnosis can be. A selected laboratory test, like cANCA is indeed an important diagnostic marker for vasculitis [1,2]. However, several infectious diseases have been reported to stimulate positive cANCA tests and therefore to mimic vasculitis. One of them is infective endocarditis, which is known to initiate the immune complex disease in about 25% of patients [3,4]. One could speculate that an immunosuppressive treatment, in our patient might have led to a blunted antibacterial response, and potentially to the expansion of the endocardial infection with the bivalvular involvement, while reducing clinical symptoms. Our patient can be a reminder of the clinical rule, that before the definitive diagnosis and treatment of suspected vasculitis, an active infection, especially IE must be excluded [5].

18F]FDG-PET/CT radiomics in patients suspected of infective endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. AIM [18F]FDG-PET/CT is part of the diagnostic algorithm for IE diagnosis. Increased [18F]FDG uptake with focal and heterogenous pattern at valve, intravalvular or perivalvular at visual analysis is consistent with IE. Diffuse, homogeneous or low valvular [18F]FDG uptake make diagnosis more challenging. Semiquantitative parameters may be of value in such case of equivocal PET findings; however, they are still not validated in IE. In this study we aim to assess the value of [18F]FDG PET/CT radiomics in IE diagnosis. Further, we build a model for radiomics-based prediction of PET/CT findings, patient classification and stratification as well as prediction of the final diagnosis. Materials and Methods We evaluated a series of [18F]FDG PET/CT scans in 447 patients (M:F =284:163, mean age 67± 16yrs), with suspected IE (519 valves, NVE = 109, PVE = 410), studied in 3 different centers between January 2015- 2020. Clinical, surgical data, antimicrobial treatment, microbiology and biochemistry, imaging and the DUKE/2015 ESC classification were collected. PET/CT images were semiautomatically segmented (Advantage Workstation, GE) and texture features extracted by LIFEx software. For the analysis we used absolute correlation exclusion criteria and PCA based dimensionality reduction, MANOVA test and LR for multivariate testing. Prior to model building by Random Forest (80% training sets, 20% test), we applied covariance matrix for correlated feature removal and SMOTE for preprocessing the imbalanced dataset. Results MANOVA and LR showed a positive contribution of radiomics in predicting PET/CT results and IE diagnosis, with a different signature in IE-positive/IE-negative patients (80% in training, 70% in validation). Of interest, the signature of patients with equivocal PET/CT findings was similar to IE-negative signature. Clustering-based stratification identify in two groups, one with milder disease presenting weak or no [18F]FDG uptake and one with more severe disease. Our LR models with incremental complexity (Table 1 and 2) demonstrated that the richer the information fed into the model the higher the performances, reaching 90% of AUC. However, the performance of model M5 and M6 is almost equal, suggesting a limited contribution of radiomics in classifying IE. Conclusion [18F]FDG PET/CT radiomics provide a limited, yet positive, contribution in the classification of EI. Nevertheless, radiomics was fundamental in defining PET outcome, thus it could support visual imaging assessment in particular when equivocal [18F]FDG findings are present. Further steps focusing on refinement of the IE diagnostic criteria, on explainable analysis on positive/negative patients to be transferred in equivocal cases. Ultimately, the identification of radiomic signature would help to define thresholds to discriminate between mild infection and severe IE, in a risk score fashion. Abstract Table 1 Abstract Table 2

Clinical and echocardiographic features of valvular aneurysms

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Valvular aneurysm (VA) is a rare disease whose etiology most frequently includes infective endocarditis but also connective tissue or degenerative myxomatous diseases or traumatism related to a remote surgical procedure. Purpose: Our study aims to describe clinical and echocardiographic features of VA. Methods: 12 years retrospective observational study. Inclusion criteria: patients (pts) found to have a VA by echocardiography (E). A VA was defined as a saccular bulging or a cyst-like outpouching of a valve leaflet that expands and collapses during systole or diastole. The ability of different E techniques in imaging and sizing the valve aneurysm and clinical data were collected. Results: In a 12 years observational period, 12 pts (7 male, 5 female) with a mean age of 41 years ± 16.6 were found to have VA as diagnosed by two experienced readers. In 10 pts there was a diagnosis of IE according to the ESC, AHA criteria. In two pts IE work up was negative. In the patient with definite IE, blood cultures were reported as positive in 7/10 pts (staphylococci 4 pts, Pseudomonas 2 pts, clostridium difficile 1) and 9 pts out of 10 pts underwent surgery and 1 died; all of them had valve replacement except one had mitral valve (MV) repair. Severe regurgitation was found in 9 cases. Associated IE features were: perforation (11 pts), abscess (3pts), vegetation (7pts), fistula (1pt), and embolism (6 pts). Echo features are reported in table 1. Transthoracic E was able to image the VA in only 3/12 pts. Discussion: The spectrum of the VA in our cohort is very unusual. We reported a VA in a bioprosthesis MV not IE related and never described, one case of valvular aneurysm in a bicuspid aortic valve, and 2 cases in the posterior mitral leaflet (PML). The etiology of VA was related to IE as the leading cause (ten in our cohort). In the two pts where no IE was diagnosed, the possible pathogenesis in one patient may have been related to a remote surgical procedure (left atrial dissection) and in the second patient to degenerative phenomena of the MV bioprosthesis. Being the imaging uncommon, it is important to not misinterpret the VA features with large vegetations, cystic lesions, and abscess. Conclusion: In our series, both the typical spectrum of the disease and less common presentations have been found. We reported one of the largest series of VA with never described unusual presentation. 2-dimensional (D) transesophageal E (TEE) was the key E modalities in the diagnosis integrated by 3D TEE allowing an anatomical imaging useful in surgical decision planning. Almost all cases were associated with perforation and severe regurgitation and a high incidence of embolism. All the cases with IE required surgery except one that died while medical therapy and follow up in the other etiologies . The unusual echocardiographic features have to be as early as possible detected in order to let the patient have the best therapeutical interventions. Abstract Table 1: Echocardiographic features Abstract Figure. Valvular aneurysm imaging