Introduction Infective Endocarditis Research Articles

Predicting in-hospital mortality in infective endocarditis: insights from complete blood count parameters and NT-proBNP

Abstract Funding Acknowledgements None. Introduction Infective endocarditis (IE) is a rare condition with an increasing incidence rate and complexity of cases over the last few years, accompanied by a high mortality rate ranging from 18% to 25%. Recent studies have shown the utility of new outcome predictors based on complete blood count (CBC), such as red blood cell distribution width (RDW) and neutrophils/lymphocytes ratio (NLR). Drawing retrospectively from an 8-year experience, we provide a perspective from a tertiary center on predictors of in-hospital mortality based on basic laboratory test results in patients with valve-related IE. Purpose The aim of the study was to assess the clinical accuracy of CBC-based parameters as in-hospital mortality predictors. Methods From a tertiary center database (serving a stable population of 2.5 million citizens), we selected all patients hospitalized due to valve-related infective endocarditis between 2015 and 2022. We analyzed clinical data (including sex, age, IE localization, and etiological factors, number of cases, management and mortality), laboratory test results at admission (including CBC parameters, C-reactive protein - CRP, procalcitonin - PCT, N-terminal prohormone of brain natriuretic peptide - NT-proBNP, estimated glomerular filtration rate - eGFR, Creatinine - Crea, urea - UR). For three NT-proBNP, NLR, and RDW we provided a further analysis to compare their clinical accuracy. Univariable logistic regression was used to assess the impact of specific factors on mortality. To determine the optimal cutoff values for predicting mortality, we analyzed the area under the curve (AUC) from receiver operating characteristic (ROC) curves and used Youden's index. P-values < 0.05 were considered statistically significant. Results A total of 194 consecutive patients with confirmed IE were included in the study, the majority of whom were men (75.3%) with an overall median age of 62 years. The overall mortality rate was 27.8%. The most common localization was left-sided IE (92.3%). In 39.7% of cases, the etiological factor was unidentified, while Staphylococcus spp. were the most common bacteria among the identified cases. We identified significant impacts on mortality in most of the analyzed laboratory tests (RDW, platelet count, hemoglobin, NLR, PCT, NT-proBNP, eGFR, Crea, UR). Results showed that for every 1000pg/ml of NT-proBNP the risk of in-hospital death increases by 6%. ROC analysis was performed for the three parameters (RDW, NLR, and NT-proBNP), and each parameter showed an acceptable area under the curve - AUC (RDW: 0.69; NLR: 0.62; NT-proBNP: 0.78). Although we found the highest AUC for NT-proBNP (p<0.001). Conclusions Although CBC parameters are easy to assess and useful in predicting in-hospital death in IE, the accuracy of NT-proBNP is higher. The management of IE cases requires a complex approach, and NT-proBNP, which also reflects the clinical state of patients, still remains a more useful tool.In-hospital deaths ROC analysis

Prognostic predictors in infective endocarditis: a registry of a reference hospital from 2016-2022

Abstract Funding Acknowledgements None. Introduction Infective endocarditis (IE) is a cardiovascular pathology with a poor prognosis due to its intra- and extracardiac complications, which sometimes contraindicate surgery and determine its prognosis. OBJECTIVES Our aim was to analyze the prognostic determinants of patients diagnosed with IE. Material and Methods We included patients admitted to a cardiac surgery referral hospital with a diagnosis of IE from 2016-2022. We documented cardiac involvement, extracardiac complications, as well as whether or not cardiac surgery was performed. Their long-term monitoring included checking for major adverse events, such as cardiovascular (CVM) and all-cause mortality (A-CM). The use of Cox regression models resulted in the establishment of prognostic determinants. Results Among 162 patients (males 70.5%; median age 66 years old, P25: 58, P75: 76), the most frequent location of IE was aortic valve (44%), followed by mitral (31.9%), mostly native (50.6%). Fifty percent of the patients were diagnosed with recently developed valve dysfunction. The most frequent local cardiac complications were abscess (21.2%) and chordal/veil rupture (10.2%). The incidence of cerebral embolism was 21.8% and shock was up to 19.9%. In-hospital mortality rate was high (24.7%), with 82.6% not having undergone surgery. At the follow-up (mean 35.7 months), it was noted that there was a rate of 22.9% CV mortality and 35.7% overall mortality; of these patients, the majority had no prior surgical intervention (69.9%). Predictors of all-cause and CV mortality at follow-up were shock (HR 4.12 CI95% 1.7-10 in CVM, p=0.02 and HR 3.8 CI95% 1.9-7.4 in A-CM, p<0.01), diabetes mellitus (CVM HR 7.82 CI95% 3.15-19.4 p<0.01; A-CM HR 2.6 CI95% 1.4-5 p<0.01), history of oncological disease (CVM HR 3.21 CI95% 1-10.3 p=0.05; A-CM HR 3.4 CI95% 1.4-7.9 p<0.01), complete atrioventricular block (CVM HR 3.03 95% 1.1-8.5 p=0.04; A-CM HR 3 CI95% 1.4-6.8 p<0.01) and valvular dysfunction (CVM HR 7.82 CI95% 3.15-19.4 p<0.01; A-CM HR 1.59 CI95% 1.1-2.4 p=0.03). Low rates of EI recurrence (6.6%) and readmission (14.6%) were detected, with no statistically significant relationship with surgery. Adjusted for valve type (aortic or mitral), operated patients had a better prognosis (HR 0.24, 95%CI 0.08-0.72, p=0.02) with a longer median survival (64.5 vs 51.1 months, p=0.05). Conclusion Infective endocarditis has a mortality rate of up to 25% in our series, mostly in-hospital, which is associated with shock, AVB, valvular dysfunction and a history of diabetes mellitus and oncological disease. Surgery seems to provide benefits regardless of the type of valve involved.

Endocardite infectieuse : facteurs prédictifs de mortalité intrahospitalière

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

Combined right and left sided endocarditis in a hemodialysis patient: A cautionary tale

IntroductionInfective endocarditis is a potentially life-threatening condition, more prevalent among chronic maintenance hemodialysis patients, as opposed to the general population.AimCombined involvement of both the right and left heart chambers is exceptionally rare.Case studyHerein, we present the case of a patient on long-term maintenance hemodialysis with right and left sided infective endocarditis.Results and discussionWe discuss potential risk factors leading to the widespread infection and emphasize the importance of an early diagnosis and prompt treatment in yielding better outcomes.ConclusionsThe patient was treated successfully by a multidisciplinary team.

Surgery versus medical therapy in patients with infective endocarditis and surgical indication: a retrospective study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infective endocarditis is a condition associated with poor outcomes. Even though we have guidelines that establish which patients could benefit from surgery, the decision to perform it is not straightforward and there are many factors to be considered before we decide surgical approach. Purpose To establish the impact of surgery versus medical treatment in patients with surgical indication according to the ESC guidelines, in our population. The primary outcome was a composite of death, embolic events, and recurrence of infective endocarditis. Methods We performed a retrospective study of the patients admitted to our center between 2000 and 2020, with the diagnosis of infective endocarditis. After selecting the patients with surgical indication, according to ESC guidelines, we divided them in two groups: group A (submitted to surgery) and group B (medical therapy only). Results A total of 70 patients (65.7% males, 34.3% females, mean age 68.5 ± 15.2) were included. Of these 51.4% were submitted to surgery and 48.6 % received only medical therapy. The group A patients were significantly younger (mean age 63.03 ± 16.03 versus 75.52 ± 10.40, p<0.001). There were no statistically significant differences in terms of previous history of heart failure (p=0.09), valvular heart disease (p=0.83), ischemic heart disease (p=0.47), diabetes (p=0.50), obesity (p=0.17), chronic kidney disease (p=0.68). In terms of local complications, group A had a higher prevalence of severe valvular regurgitation (72.2% vs 36.4%, p= 0.003), with no statistically significant differences in abscess, aneurysm, fistula. During a mean follow-up of 28.66 ± 39.07 months, 42 pts (60%) experienced the composite endpoint. Group A had significantly better outcomes compared to group B (47.2% versus 26.5%, p= 0.016). In a multivariate regression analysis, after adjusting for all the possible confounders, including age, not performing surgery was an independent predictor of the composite endpoint (HR 2.23 95% CI: 1.16-4.55, p=0.02). Conclusion In patients with surgical indication, surgery was associated with a significant improvement in prognosis. In our population, older patients were more likely to receive medical therapy. However, surgery was associated with better outcomes, independently of age, which suggests that this shouldn’t be the only factor that determines whether surgery is performed or not.

Abstract Number: LBA23 Endovascular treatment of large vessel occlusion stroke caused by infective endocarditis

Introduction Infective endocarditis (IE) often presents as an acute ischemic stroke (AIS) secondary to a thromboembolic event leading to large vessel occlusion (LVO). These patients are at significant risk for intracerebral hemorrhage when given intravenous thrombolytics (IT) and are therefore better candidates for mechanical thrombectomy (MT). Current reports in the literature are divided on the safety of MT in this setting and no randomized control studies exist. With the advent of modern thrombectomy devices, we believe MT might be safe in this patient population. Methods Here we report a patient with IE who presented with LVO stroke (MCA syndrome) and underwent MT leading to first‐pass Thrombolysis inCerebral Infarction (TICI) score of 3 revascularization. In addition to presenting our case, we did a comprehensive review of the current literature on this topic. Results A thirty‐year‐old female with a history of cocaine abuse presented with acute onset left hemiplegia, dysarthria, and rightward gaze deviation. NIHSS was 19 and she presented 90 minutes from her last known well time . Computed Tomography (CT) head and CT perfusion imaging demonstrated a large MCA distribution stroke, an AlbertaStrokeProgram Early CT Score (ASPECTS) of 10, with significant perfusion mismatch of right MCA territory. CT angiography (CTA) confirmed a proximal large vessel occlusion (LVO) at the proximal M1. On initial assessment, the patient was febrile with a temperature of 40 degrees Celsius with a high clinical suspicion for IE; therefore, intravenous thrombolytic was not administered. MT was performed with one pull of stent retrieval under aspiration led to a successful opening of the vessel with TICI score of 3. Positive cocaine on urine toxicology was noted as well as, two sets of gram‐positive blood cultures which later resulted in Staph Aureus, oxacillin susceptible, unremarkable transthoracic echo, but with TEE demonstrating vegetative thickening within atrial aspects of both anterior andposterior mitral valve leaflets(Figure1). On hospital day two, magnetic resonance imaging of the brain shows small acute infarct with no bleed. The patient underwent a mitral valve replacement on hospital day nine. The patient was discharged to rehabilitation facilities with an NIHSS of two for mild left facial droop and mild left arm weakness; her degree of disability was measured as a modified Rankin Scale (mRS) one at 3 months. Conclusions In case IE is suspected, giving IV tPA (tissue‐type plasminogen activator) is contraindicated as it increases the chance of hemorrhagic complications and when LVO is confirmed in the setting of AIS, MT might be safe and effective to be considered .

Reparación valvular en la endocarditis mitral

IntroductionInfective endocarditis (IE) is a pathology with a high morbidity and mortality rate and represents a growing public health problem. Surgical treatment is necessary in more than half of the cases, and its main purpose is to completely remove the infected tissue and reconstruct normal cardiac anatomy, including repair or replacement of the affected valve(s). Objectives and methodsThe present study focuses on describing the most appropriate procedure for mitral repair surgery in cases of IE, based on the literature and the extensive experience gained by the surgical team. Likewise, we have compiled through a systematic search of the literature the results that have been reported on reparative surgery compared to mitral valve replacement. ResultsThe surgical technique described requires a thorough study of the degree of involvement and destructuring of the different valve segments. We consider resection with pericardial patch interposition and/or Goretex® neochord implantation to be the standard technique that allows reproducible results. The structured review of the available scientific evidence verifies the safety of mitral repair for the treatment of IE, providing significant benefits compared to valve replacement. ConclusionThe evaluated surgical results suggest that mitral repair surgery should be considered the procedure of choice for the surgical treatment of IE, whenever technically feasible.

The LAUsanne STAPHylococcus aureus ENdocarditis (LAUSTAPHEN) score: A prediction score to estimate initial risk for infective endocarditis in patients with S. aureus bacteremia.

Infective endocarditis (IE) is a common complication of Staphylococcus aureus bacteremia (SAB). The study aimed to develop and validate a prediction score to determine IE risk among SAB. This retrospective study included adults with SAB (2015-2021) and divided them into derivation and validation cohorts. Using the modified 2015 European Society of Cardiology modified Duke Criteria for definite IE, the LAUSTAPHEN score was compared to previous scores. Among 821 SAB episodes, 419 and 402 were divided into derivation and validation cohorts, respectively. Transthoracic and transoesophageal echocardiography (TOE) were performed in 77.5 and 42.1% of episodes, respectively. Definite IE was diagnosed in 118 episodes (14.4%). Derivation cohort established that cardiac predisposing factors, such as cardiac implantable electronic devices, prolonged bacteremia ≥48 h, and vascular phenomena were independently associated with IE. In addition to those parameters, native bone and joint infections were used to constitute the LAUSTAPHEN score. LAUSTAPHEN and VIRSTA scores misclassified <4% of IE cases as low risk. Misclassification using POSITIVE and PREDICT scores was >10%. The number of TOEs required to safely exclude IE were 66.9 and 51.6% with VIRSTA and LAUSTAPHEN, respectively. LAUSTAPHEN and VIRSTA scores exhibited the lowest misclassification rate of IE cases to the low-risk group. However, the number of patients requiring TOE was higher for VIRSTA than for LAUSTAPHEN.

Infective endocarditis: Epidemiology and prognosis

IntroductionInfective endocarditis (IE) is associated with high morbidity and mortality, despite advances in diagnosis and treatment. ObjectiveTo assess changes in the epidemiological profile of IE, to perform a time-trend analysis and to define short-term and long-term prognostic predictors of IE. MethodsRetrospective analysis of 173 patients admitted with a diagnosis of IE to a Portuguese level II Hospital between January 1998 and December 2013. The patients were divided into two groups according to the period of occurrence of the IE episode (1998-2007 vs. 2008-2013). The clinical event studied was the occurrence of death or the need for urgent surgery during hospitalization, and death in the follow-up period. Independent predictors of short-term and long-term prognosis were identified. ResultsIn the first portion of the study, IE occurred in younger individuals, often drug addicts, users of intravenous drugs and with gastrointestinal disease, human immunodeficiency virus and hepatitis B infection. In the second portion of the study, IE occurred more frequently in individuals of an older age with concomitant cardiovascular disease; enterococcus was isolated more frequently. The independent predictors of in-hospital death or need for urgent valve surgery were septic shock and the occurrence of peri-annular complications. The independent predictors of long-term mortality were age, chronic kidney disease and IE due to multidrug-resistant microorganisms. ConclusionDifferences were found in the epidemiological profile of IE during the study period. Referral for valve surgery increased slightly, but mortality remained high.

The Global, Regional, and National Burden and Trends of Infective Endocarditis From 1990 to 2019: Results From the Global Burden of Disease Study 2019.

IntroductionInfective endocarditis (IE) presents with increasing incidence and mortality in some regions and countries, as well as serious socioeconomic burden. The current study aims to compare and interpret the IE burden and temporal trends globally and in different regions from 1990 to 2019.MethodsData on the incidence, deaths and disability-adjusted life years (DALYs) caused by IE were extracted and analyzed from the Global Burden of Disease Study 2019. Estimated annual percentage changes (EAPC) were adopted to quantify the change trends of age-standardized rates (ASRs). Besides, potential contributors of serious IE burden were also evaluated including age, gender, social-demographic index (SDI), and age-standardized incident rate (ASIR) in 1990.ResultsGlobally, the number of IE cases and deaths has increased sharply during the past 30 years from 478,000 in 1990 to 1,090,530 in 2019 and from 28,750 in 1990 to 66,320 in 2019, and both presented an upward temporal trend annually (EAPC:1.2 for incidence and 0.71 for death). However, the EAPC of age-standardized DALYs demonstrated a negative temporal trend despite increasing DALYs from 1,118,120 in 1990 to 1,723,590 in 2019. Moreover, older patients and men were more severely affected. Meanwhile, different SDI regions had different disease burdens, and correlation analyses indicated that SDI presented a positive association with ASIR (R = 0.58, P < 0.0001), no association with age-standardized death rate (R = −0.06, P = 0.10), and a negative association with age-standardized DALYs (R = −0.40, P < 0.0001). In addition, the incidence of IE increased in most countries during the past 30 years (190 out of 204 countries). However, the change trends of deaths and DALYs were heterogeneous across regions and countries. Finally, we discovered positive associations of the EAPC of ASRs with the SDI in 2019 among 204 countries and territories but few associations with the ASIR in 1990.ConclusionGenerally, the global burden of IE is increasing, and there is substantial heterogeneity in different genders, ages and regions, which may help policy-makers and medical staff respond to IE and formulate cost-effective interventional measures.

Suggested modification of the recommendations for echocardiography in patients with clinical suspicion of infective endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is often necessary because of its higher sensitivity for IE compared with TTE. Yet, TOE has an increased risk of complications. The European Society of Cardiology (ESC) has established guidelines for the management of IE with recommendations for the use of TOE in patients with clinical suspicion of IE. Purpose This project aims to evaluate the ESC recommendations for the use of TOE in patients with clinical suspicion of IE. The purpose of the study is further to examine whether the ESC recommendations for TOE among patients with clinical suspicion of IE result in an unnecessarily large number of negative TOE examinations. Methods All TOE examinations performed due to referrals of patients with clinical suspicion of IE between 1 May 2019 and 30 April 2020 at a university hospital in our city were analysed. The variables included for analysis were age; sex; cardiac comorbidities; prosthetic valves; blood culture results; results from TTE and TOE; number of TOEs during the inclusion period; Duke criteria. The TOE and TTE results were compared in relation to the ESC guidelines. Results In total 195 TOE examinations from 160 patients were included, of which 61 (31%) TOEs were positive for IE. All examinations were of patients with clinical suspicion of IE, of which 37 (19%) had negative TTE. Of the 37 patients with negative TTE, 13 had prosthetic valve or intracardiac device of which 5 had positive TOE. All the 24 (12%) examinations with negative TTE and no prosthetic valve or intracardiac device had negative TOE. Conclusions The ESC recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients that get referred for TOE with negative results. To avoid this, we propose a modification of the recommendations for TOE in patients with clinical suspicion of IE. Negative TTE examination with good image quality and no indications for TOE according to Fig 1, could result in avoiding unnecessary TOE examinations without jeopardizing the IE diagnosis. Abstract Figure. Fig 1

Infective endocarditis in octogenarians: a retrospective study in a single surgical center

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infective endocarditis (IE) is a severe disease associated with high morbidity and mortality. The EURO-ENDO registry reported a mean age of 59.25 ± 18.03 years; 46.3% of patients were over 65 and 12.0% over 80 years. Little is known about the best management of elderly patients with IE. In these patients, surgery may be challenging. Purpose We aimed to determine the clinical and echographic characteristics, the therapeutic strategy, and the outcome of IE in octogenarians. Method We retrospectively included in the analysis 457 consecutive patients with definite active IE in a single surgical centre. Descriptive statistics are reported as mean ± standard deviation (SD) or median ± interquartile range (IQR) for continuous variables with normal and non-normal distribution and as frequencies and percentages for categorical variables. Between-groups comparisons were assessed by Student’s t-test, Mann-Whitney U test, Kruskal-Wallis, or chi-square test, as appropriate. Univariate long-term survival was analysed by the Kaplan-Meier method. Results In our cohort, octogenarians were 17% of the whole population (N = 77). In patients under the age of eighty, males were mostly involved with a sex ratio exceeding 2:1. This ratio was inverted in older people, where the female gender represented 57% of the total (0.001). Staphylococcus aureus (10.4 vs 20.5%, p =0.038) and Enterococci (29.9 vs 16.3%, p =0.008) were significantly less and more frequent than in younger people, respectively. Comorbidities were more frequent in elderly patients, such as hypertension (80.5 vs 53.2%, p = 0.001), dyslipidaemia (42.7 vs 27.3%, p = 0.008), and history of cancer (29.9 vs 19.2%, p = 0.036). Consequently, EUROSCORE II was higher (median ± IQR 19.18 ± 19.0 vs 11.9 ± 5.7, p = 0.001). In octogenarians, IE was more frequently left-sided (98.7 vs 89.2, p = 0.009) and complicated less often with peripheral embolism (31.2 vs 43.9%, p = 0.038). We found no differences between the two groups for the type of infected valve (native or prosthetic), the severity of valve dysfunction, paravalvular extension, and vegetation length. Octogenarians were more often excluded from surgery despite indication (19.5 vs 7.7%, p = 0.016) and had higher thirty-day (11.7 vs 7.9%, p = 0.001) and three-year (45 vs 30%, p = 0.001) mortality than younger patients. Conclusions Octogenarians represent a considerable proportion of overall cases of IE, with specific clinical and microbiological characteristics. Older patients are more often excluded from surgery, and the overall prognosis is poor. Abstract Figure.

COMBINED TREATMENT WITH IGM ENRICHED IMMONOGLOBULIN AND CYTOSORB IN INFECTIVE ENDOCARDITIS: CASE SERIES

Introduction Infective endocarditis is a serious disease condition. Depending on the causative microorganism and clinical symptoms, cardiac surgery and valve replacement may be needed, posing additional risks to patients who may simultaneously suffer from septic shock. The combination of surgery bacterial spreadout and artificial cardiopulmonary bypass (CPB) surfaces results in a release of key inflammatory mediators leading to an overshooting systemic hyperinflammatory state frequently associated with compromised hemodynamic and organ function.(1) Combined use of hemoadsorption (2)and IgM enriched Immunoglobulin (3) might represent a potential approach to control the hyperinflammatory systemic reaction associated with the procedure itself and subsequent clinical conditions by reducing a broad range of immuno-regulatory mediators and endotoxemia. Methods We describe retrospectively 8 cardiac surgery patients with proven acute infective endocarditis obtaining valve replacement with CPB surgery in combination with intra e postoperative CytoSorb hemoadsorption and intravenous administration of IgM enriched Immunoglobulin (Pentaglobin®) 250 mg/kg die. for three consecutive days Results Combined treatment of hemoadsorption and IgM enriched Immunoglobulin was associated with a mitigated postoperative response of key cytokines (4) with a significative reduction of IL-6 and Endotoxemia (5) an increase of IL10 (6); an improvement of clinical metabolic parameters (WBC and SOFA score). Moreover, patients showed hemodynamic stability which possibly could be attributed to the additional combined treatment. Intraoperative hemoperfusion and Pentaglobin administration were well tolerated and safe without the occurrence of any related adverse event. Discussion Conclusion: This approach may open up potentially promising therapeutic options for infective endocarditis, with pro and antiflammatory modulation, improved hemodynamic stability and organ function as seen in our experience.

A Seventeen-Year Descriptive Study of Infective Endocarditis Features at a Tertiary, Teaching Hospital.

IntroductionInfective endocarditis (IE) is a microbial infection affecting the endothelial lining of the heart chambers and valves. Despite advances in diagnostic methods and management, IE still carries high levels of morbidity and mortality. There are no comprehensive data describing incidence, risk factors, and outcomes of IE in Saudi Arabia.Our study aims to describe the epidemiological and clinical characteristics and outcomes of adult patients with IE treated in a tertiary, Teaching Hospital.MethodsThis is a descriptive, retrospective review of charts (between January 2003 and June 2019) conducted at King Abdulaziz University Hospital. We included all patients 16 years and older with a definitive diagnosis of IE based on Duke Criteria. We collected the following information: demographics, risk factors, comorbidities, microbial type, antibiotic choice, complications, laboratory data, echocardiography data, and mortality.ResultsWe found a total of 60 adult patients with definitive diagnoses of IE: 55% of them were males, and the mean age was 48.71 ± 18.3 years. Hypertension was the most common comorbidity, affecting 23 patients (38.3%), followed by end-stage renal disease (ESRD) in 20 patients (33.3%) and diabetes in 17 (28.3%). Staphylococcus aureus was the most common organism (25%), and vancomycin was the most prescribed antibiotic. Fifty-eight patients were treated medically (96.5%). Furthermore, 88% of the patients had vegetations, detected by echocardiography, and the majority had single-valve involvement. Sepsis was the most common complication, and the mortality rate was 36.7%.ConclusionThere was a small number of definitive IE cases over a 17-years span in our institution. Surprisingly, a higher mortality rate was found among our patients and a lower surgical intervention rate in comparison with the literature. Though we acknowledge the limitations of a retrospective, chart review study, we can speculate that the high mortality rate may be in part related to a higher number of virulent organisms, delayed presentation, and lack of prompt surgical intervention.

Cutaneous Vasculitis and Generalized Lymphadenopathy Associated with Extended-Spectrum Beta-Lactamase (ESBL)-Producing Escherichia coli Endocarditis: A Rare Case Report.

IntroductionInfective endocarditis (IE) has been known as the great imitator due to variable clinical manifestation, making its diagnosis challenging. A missed diagnosis could lead to inappropriate therapy. We presented a rare case of blood culture-negative infective endocarditis (BCNIE) due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli manifest with cutaneous vasculitis and generalized lymphadenopathy. We highlighted its diagnostic challenge and management.Case Illustration and DiscussionA 36-year-old male with known asymptomatic ruptured sinus of Valsalva (SOV) presented with fever of unknown origin for six months, fatigue, weight loss with a history of multiple hospitalizations. The physical examination revealed a continuous murmur at Erb's point, cutaneous vasculitis, and bilateral inguinal lymphadenopathy. The laboratory result was leukocytosis and elevated C-Reactive Protein (CRP). Generalized lymphadenopathy was detected from the thorax and abdominal Computed Tomography (CT) Scans. Positive Anti Nuclear Antibody (ANA) Indirect Immunofluorescence (IF) speckled pattern led us to consider an autoimmune as the etiology, but we still considered IE as a differential diagnosis due to history of structural heart disease. Detection of multiple tiny oscillating masses at the tricuspid valve from the echocardiogram and cardiac CT led to possible IE diagnosis. Negative three consecutive blood cultures led the diagnosis to BCNIE. Surgery was performed to evacuate the vegetations, repair the SOV, and tricuspid valve replacement with a bioprosthetic valve. These results in improvement of the patient’s condition. ESBL-producing Escherichia coli yielded in tissue culture made the diagnosis of IE became definite.ConclusionESBL-producing Escherichia coli should be considered as the etiology of BCNIE. Cutaneous vasculitis and generalized lymphadenopathy as a manifestation of IE could lead to diagnostic confusion. A thorough investigation will help clinician to avoid delay or inappropriate treatment that could be detrimental for the patient.

Clinical characteristics and outcome of infective endocarditis among intravenous drug abusers in India

IntroductionInfective endocarditis (IE) is the most dreaded complication of intravenous drug abuse (IVDA). IVDA is present in significant proportions in India. Since there is scarcity of Indian data on IVDA associated IE, we report a study comparing IVDA to non IVDA associated IE. We compare differences in clinical profile, microbiology, echocardiography and clinical outcome from a tertiary care hospital. MethodsA total of 133 patients admitted from 1st January 2017 to 31st December 2019 who met the Modified Duke ‘‘definitive’’ criteria for IE were included. Detailed Information was collected regarding demography, clinical data and laboratory investigations. All patients underwent transthoracic echocardiography and trans-esophageal echocardiogram wherever necessary. ResultsAmong a total of 133 patients, 54 patients (40.6%) were iv drug abusers. Patients in IVDA-group were younger, mostly males, more likely to have concomitant HCV and HIV infections compared to non IVDA-group. Chronic comorbidities such as DM and CKD were more common in non IVDA-group. Rate of positive blood culture was higher in IVDA-group compared to non IVDA-group (74.1%v/s 32.9%,p < 0.001) with different microbiological profile. Percentage of Methicillin resistant staphylococcus aureus (42.6%v/s17.7%,p = 0.003) and pseudomonas related IE (18.5%v/s2.5%,p = 0.003) was significantly higher among IVDA-group. IVDA-group most commonly had tricuspid valve involvement Whereas mitral and aortic valve were most commonly involved valve in non IVDA-group. Mortality was slightly higher among IVDA-group compared to non IVDA-group, though statistically non-significant. Left sided valve involvement and Congestive heart failure were independent predictors of mortality. ConclusionIVDA-IE is a significant problem in India. Demographic, microbiological and echocardiographic profile is quite different in IVDA and non IVDA-group. There is urgent need to conduct larger studies.

Cardiac surgery in infective endocarditis and predictors of in-hospital mortality

Abstract Introduction Infective endocarditis (IE) is a serious disease with significant in-hospital mortality (15–30%) despite advances in medical and surgical therapy. Aims To perform a clinical characterization of patients undergoing cardiac surgery for IE and to identify factors that predict in-hospital mortality. Methods We retrospectively analyzed 145 patients with IE admitted between January 2006 and October 2017. Results The median age was 72 years. IE was acquired mainly in the community (69%), and involved the native aortic valve in 54% of patients, biological prosthetic valves in 22.1% and mechanical valves in 10.3%. Staphylococcus spp. (31.0%) were the most frequent etiological agents. Cardiac surgery was emergent in 29 patients, urgent in 108, and elective in eight. The main indications were heart failure (57.9%), large vegetations (20%), systemic embolism (17.2%) and valve dysfunction (15.2%). Overall, biological valves were implanted in 62.1% of patients and mechanical valves in 37.2%. A total of 19 patients (13.1%) died. Predictors of mortality were preoperative atrial fibrillation and lower left ventricular ejection fraction, postoperative severe valve regurgitation associated with cardiogenic shock, sepsis, septic shock associated with cardiogenic shock, cardiac tamponade, need for renal replacement therapy and, although without statistical significance, emergent surgery. Conclusions There is a need for better indicators to enable early identification of surgical candidates for IE, implementation of a heart team, and better surgical strategies, including more rapid intervention, more specific postoperative care, and optimal antibiotic therapy.

Assessing efficacy of CytoSorb haemoadsorber for prevention of organ dysfunction in cardiac surgery patients with infective endocarditis: REMOVE-protocol for randomised controlled trial

IntroductionInfective endocarditis (IE) is associated with high mortality and morbidity. Multiple organ failure is the main cause of death after surgery for IE. Cardiopulmonary bypass (CPB) can cause a systemic...

Cirurgia cardíaca na endocardite infeciosa e preditores da mortalidade intra‐hospitalar

IntroductionInfective endocarditis (IE) is a serious disease with significant in‐hospital mortality (15‐30%) despite advances in medical and surgical therapy. AimsTo perform a clinical characterization of patients undergoing cardiac surgery for IE and to identify factors that predict in‐hospital mortality. MethodsWe retrospectively analyzed 145 patients with IE admitted between January 2006 and October 2017. ResultsThe median age was 72 years. IE was acquired mainly in the community (69%), and involved the native aortic valve in 54% of patients, biological prosthetic valves in 22.1% and mechanical valves in 10.3%. Staphylococcus spp. (31.0%) were the most frequent etiological agents. Cardiac surgery was emergent in 29 patients, urgent in 108, and elective in eight. The main indications were heart failure (57.9%), large vegetations (20%), systemic embolism (17.2%) and valve dysfunction (15.2%). Overall, biological valves were implanted in 62.1% of patients and mechanical valves in 37.2%. A total of 19 patients (13.1%) died. Predictors of mortality were preoperative atrial fibrillation and lower left ventricular ejection fraction, postoperative severe valve regurgitation associated with cardiogenic shock, sepsis, septic shock associated with cardiogenic shock, cardiac tamponade, need for renal replacement therapy and, although without statistical significance, emergent surgery. ConclusionsThere is a need for better indicators to enable early identification of surgical candidates for IE, implementation of a heart team, and better surgical strategies, including more rapid intervention, more specific postoperative care, and optimal antibiotic therapy.

Towards identification of novel putative biomarkers for infective endocarditis by serum proteomic analysis

IntroductionInfective endocarditis (IE) has high mortality, partly due to delayed diagnosis. No biomarker can identify IE in patients with fever and clinical picture of infection. To find putative biomarkers we analyzed serum levels of two proteins found in cardiac valves, fibulin-1 (n=696) and osteoprotegerin (n=689) among patients on clinical suspicion of IE. Proteomic analyses were performed in 24 patients with bacteremia, 12 patients with definite IE and 12 patients with excluded IE. MethodsFibulin-1 and osteoprotegerin were studied by enzyme linked immunosorbent assay (ELISA). Proteomic analyses were conducted by 2-dimensional polyacrylamid gel electrophoresis (2D-PAGE) and label-free quantitative liquid chromatography - tandem mass spectrometry (LFQ LC-MS/MS). Controls for 2D 2D-PAGE and LFQ LC-MS/MS had bacteremia and excluded IE. ResultsOsteoprotegerin levels were significantly increased in IE patients compared with non-IE patients. Fibulin-1 showed no difference. 2D-PAGE showed significant differences of 6 proteoforms: haptoglobin, haptoglobin-related protein, α-2-macroglobulin, apolipoprotein A-I and ficolin-3. LFQ LC-MS/MS analysis revealed significant level changes of 7 proteins: apolipoprotein L1, complement C1q subcomponent B and C, leukocyte immunoglobulin-like receptor subfamily A member 3, neuropilin-2, multimerin-1 and adiponectin. ConclusionsThe concentration changes in a set of proteoforms/proteins suggest that stress and inflammation responses are perturbed in patients with IE compared to patients with bacteremia without IE.