Large Vegetation Research Articles

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.

The combined effects of tree shelters, large stock and vegetation control on the early growth of conifer seedlings

ABSTRACT Tree shelters are effective in enhancing early survival and growth and protecting planted seedlings against herbivory by mammals; they are, however, expensive. In order to be cost-effective, we need to employ silvicultural practices that maximize the benefits of using tree shelters. Thus, this study examined whether tree shelter effects on early seedling growth are enhanced by the combination of large stock and vegetation control, based on a three factor split-plot experiment for the first three years after planting the seedlings out in a fenced plantation of Japanese cedar (Cryptomeria japonica). Vegetation control involved spot and strip weeding to reduce labor costs. The experiment demonstrated the great effect of tree shelters on enhancing the early height growth of seedlings. At the end of the third growing season, sheltered seedlings were 1.5 times taller than unsheltered seedlings on average, and approximately two-thirds of sheltered seedlings had exceeded the browsing height of deer, while unsheltered seedlings had not. Using large stock and employing vegetation control also positively affected seedling height. However, combining these treatments with tree shelters intensified the positive effects on seedling height, and shortened the period during which the leader shoots of seedlings would be unprotected from the browsing without fencing. The present study thus reveals that the combination of tree shelters, large stock and vegetation control is effective in maximizing the benefit of tree shelter installation.

Value of 18F-FDG pet/CT for prognostic assessment in patients with infective endocarditis

Background 18F-FDG PET/CT is a valuable diagnostic tool in infective endocarditis (IE). However, the prognostic value is unclear. This study aims to evaluate the prognostic performance of 18F-FDG PET/CT in native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). Methods We retrospectively included 76 patients treated for definite IE (NVE and PVE) that underwent 18F-FDG PET/CT between January 2016 and December 2018. Clinical, echocardiographic and 18F-FDG PET/CT (pathologic valvular 18F-FDG uptake, extracardiac complications (ECC)) data were collected. The primary endpoint was defined as mortality or recurrence of IE at a one-year follow-up. Results Pathologic valvular 18F-FDG uptake was detected in 32 of 57 (56.1%) patients, 30% (9/30) in NVE and 85.2% (23/27) in PVE group. Atrial fibrillation (OR 3.90, 95% CI = 1.14–16.3), prior anticoagulation treatment (OR 6.37, 95% CI = 1.89–26.7), large vegetation (≥ 10 mm) (OR 4.05, 95% CI = 1.14–16.1), perivalvular complications (OR 7.22, 95% CI = 1.68–55.1) and abscess (OR 10.9, 95% CI = 1.84–283) were associated with positive PET/CT. Extracardiac complications were found in 27 of 76 (35.5%) patients, 42.9% (18/42) in the NVE and 26.5% (9/34) in the PVE group. Pathological valvular tracer uptake (HR 1.20, 95% CI = 0.43–3.37) or extracardiac complications (HR 0.58, 95% CI = 0.21–1.62) were not associated with the occurrence of the primary endpoint. Conclusion Our study could not demonstrate a prognostic value of 18F-FDG PET/CT in IE, but confirms high diagnostic performance, which may compromise prognostic significance by accelerated optimal treatment because of earlier diagnostic certainty.

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

Infective Endocarditis in Children with Isolated VSD: A Single Center Study

Aim: To determine the characteristics of isolated ventricular septal defect (VSD) in association with infective endocarditis (IE) among children with isolated VSD and its outcome. Method: This was cross-sectional study. Data was collected prospectively from infective endocarditis patients with isolated ventricular septal defect (VSD), admitted in pediatric cardiology ward of The Children’s hospital and Institute of Child Health, Lahore. Study period was from September 2018 till March 2021. The data was analyzed by using SPSS-26. Result: Sixty patients of ventricular septal defect (VSD) with infective endocarditis (IE), fulfilling the inclusion criteria, were included in the current study. Mostly about 60% were male. Transthoracic Echocardiography was done for all the patients. Single vegetation was found among 68.3%, rest were having multiple vegetations. seen. Approximately 57% were having small size vegetations while remaining 43% were with moderated – large vegetations. Complications were reported in only 18% of the study population. Regarding outcome majority of the patients (90%) were successfully treated with medical management alone, while only 8.3% required surgical intervention as well. Only 1 out of 60 patients included in the study was expired. Characteristic of VSD, size of vegetation, and number of vegetations have significant influence on development of complications (p = <0.05). Conclusion: Risk of complications among infective endocarditis with isolated VSD is comparatively greater with large vegetation and multiple number of vegetations as compared to single or small vegetation. Medical management is main stay of treatment while surgical intervention is usually required among infective endocarditis patients with DCSA-VSD & subaortic-VSD. Key words: Ventricular septal defect (VSD), DCSA (doubly committed sub-arterial) VSD, Infective endocarditis (IE).

Impact of early surgery in non-complicated left-sided native-valve infective endocarditis with large vegetations

The impact of early surgery for patients with left-sided native-valve infective endocarditis (LS-NV-IE) with a large vegetation (between 10 and 30 mm), free of embolic events and of other complication, has not yet been established. We aimed to describe the characteristics of these patients and to assess the impact of early surgery (≤ 7 days) in terms of 6-month outcomes. Among 1340 patients diagnosed with LS-NV-IE, 174 patients with a vegetation between 10 and 30 mm and without class I or IIa indication for surgery (according to European guidelines) were included. The primary endpoint combined death and endocarditis complications (recurrence of endocarditis, heart failure requiring hospitalization, or clinical embolic event) at 6-months. Patients( n = 42) who underwent early surgery were younger ( P = 0.019) and more likely to have a vegetation length > 15 mm (66.7%vs.47.7%) and highly mobile vegetations (59.5%vs.39.4%), than patients managed conservatively. The 6-month event-free survival was 98 ± 2% in the early surgery group and 86 ± 3% in the conservative group ( P = 0.037), even after propensity matching ( P = 0.003). On multivariable analysis, early surgery was associated with better outcome [Adjusted HR(95%CI) = 0.16(0.04–0.97); P = 0.046] ( Fig. 1 ). Early surgery for patients with LS-NV-IE and vegetation between 10 and 30 mm, free of embolic events and of other IE complication, is associated with a lower rate of events at 6 months.

Bicuspid aortic valve, aortic coarctation, and infective endocarditis in a young adult male

A33-year-old young male patient with a history ofuncontrolled hypertension was referred to my clinic due to a2-week fever, generalized body aches, shortness of breath,and easy fatigue. Clinical examination showed a toxic dyspneicpatient, but conscious and well-oriented. His blood pressure was170/100 mm Hg, pulse 90 beat/min, respiratory rate 15/min,and the temperature was 38.6°C. Cardiac examination showed aharsh systolic murmur at the mitral area radiating to the axilla.Abdomen examination revealed moderate splenomegaly and mildhepatomegaly. The rest of the examination was unremarkable.A bedside transthoracic echocardiogram revealed mitral valvedestruction with large vegetation (Fig. 1) and severe regurgitationconsistent with mitral valve endocarditis (modified Duke criteriafulfilled). Furthermore, bicuspid aortic valve (BAV) was viewed(Fig. 2). Suprasternal view showed a picture consistent with aorticcoarctation (CoA) (Fig. 3a and b). The patient was diagnosed withsubacute endocarditis, CoA of aorta and BAV, and broad-spectrumantibiotics were started. Despite completion of antibiotics, thevegetation persisted, and he was referred to cardiac surgery unitfor mitral valve replacement and surgical correction of CoA byend to end anastomosis.

Left ventricular pseudoaneurysm associated with infective endocarditis: an autopsy case report

BackgroundInfective endocarditis (IE) is a bacterial infection of the heart valves or endocardium, with complications such as valve perforation, ring abscess, fistula, or damage to the subaortic structures. This case report aims to illustrate an atypical complication of IE which is a pseudoaneurysm depicting a periannular hemorrhage.Case presentationWe describe a case of a 19-year-old male youth who presented with fever and cough a few days prior to his demise. There was no known risk factor for IE. The autopsy revealed a bulging anterior surface, upper part of the left ventricle which was soft and slightly fluctuant. Cut section of the heart revealed large vegetations affecting the right and left coronary cusps of the aortic valve. The vegetations at the left coronary cusp were mobile, with necrotic and hollow area underneath, appearing like a cavity and containing blood clots. The course of the cavity was determined to be at the periannular region and contained within the myocardium. These findings were consistent with left ventricular pseudoaneurysm. Culture of the vegetations specimen yielded growth of Granulicatella adiacens sp. anti-streptolysin O titre (ASOT) was 400 IU/mL and reported as positive.ConclusionsIE secondary to Granulicatella sp is rare and may result in catastrophic complications. Therefore, this case report is intended to highlight the autopsy findings of the disease as well as to create awareness of its subtle clinical symptoms.

Reassessment of Vegetation Size as a Sole Indication for Surgery in Left-Sided Infective Endocarditis

Guidelines recommend surgery for left-sided infective endocarditis (LSIE) that is associated with large vegetations. Given that most patients who undergo surgery also have other indications (heart failure and/or uncontrolled infection), it is not settled whether surgery should be routinely recommended in patients with large vegetations but no other predictors of poor outcome. A total of 726 patients with definitive LSIE were included in our analysis. The mean age was 64.9years, and 61% were male. Multivariate analysis of all patients was performed to determine whether vegetation size is related to death in LSIE. Then patients were divided into two groups according to vegetation size: group A (>10mm, n=420) and group B (≤10mm, n=306). Univariate and multivariate analyses of group A patients were carried out to identify the variables related to death in this group. The impact of surgery on mortality in group A patients without heart failure or uncontrolled local infection (n=139) was assessed. Age, Staphylococcus aureus, perivalvular complications, heart failure, kidney failure, and septic shock, but not vegetation size, were associated with death. Patients with large vegetations showed increased mortality (31.7% in group A vs 24.8% in group B; P=.045). Group A had more valve rupture and valve regurgitation than group B, but heart failure (55% vs 53%; P=.678), stroke (22% vs 17.0%, P=.091), systemic embolism (39% vs 32%; P=.074), perivalvular complication (28% vs 28%; P=.865), and septic shock (15% vs 13%; P=.288) were similar in both groups. In patients from group A without heart failure or uncontrolled infection, mortality was similar with and without surgery (n=139; n=70 with surgery and n=69 without surgery; mortality, 18.6% vs 11.6%, respectively; P=.251). Large vegetations identify patients with poor outcomes in the context of LSIE. However, surgery is not associated with a better prognosis in patients with large vegetations if they do not present with another predictor of poor outcome such as heart failure or uncontrolled infection. These findings challenge whether vegetation size alone should be an indication for surgery in LSIE.

The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction.

Recent studies have shown that Evolution RL bidirectional rotational mechanical sheath (Cook Medical, USA) is an effective and safe technique for transvenousleadextraction (TLE). We reported our experience with the bidirectional rotational mechanical toolsusing a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. The study population comprised 84 patients (77% male; mean age 65 ± 18 years) undergoing TLE. After a multidisciplinary evaluation, a combined procedure was considered. The main indication for TLE was infection in 54 cases (64%). Overall, 152 leads were extracted with a mean implant duration of 94 ± 63 months (range 12-421). Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6% (77/84), 97.6% (82/84), and 98.6% (150/152), respectively. Eighteen combined procedures were performed in 12 patients (14%), such as "hybrid approach" (n=2) or TLE concomitant to: 1) transcatheter aspiration procedure for large vegetation (n=8); 2) left ventricular assistance device implantation as bridge to cardiac transplantation (n=1); 3) permanent pacing with epicardial leads (n=6); 4) tricuspid valve replacement (n=1). One major complication (1.2%) and 11 (13%) minor complications were encountered. No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21 ± 18 months, 17 patients (20%) died. They were more often diabetics (p=.02), and they underwent TLE more often for infection (p=.004). Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the Evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators.

672 Isolated pulmonic valve endocarditis. AN unusual case with giant vegetations detected by transthoracic echocardiography

Abstract Aims Isolated pulmonic valve infective endocarditis (PV-IE) is a rare form of endocarditis. Methods and results The authors report a case of giant vegetations detected by transthoracic echocardiography on pulmonic valve in a 33 year-old patient, with drug abuse history (Figure 1). Patient underwent surgical intervention by pulmonary valved bioconduit implantation. After operation a pulmonary embolism episode was treated by a direct oral anticoagulant. The final outcome was favourable. We report a short review of this rare pathology. Conclusions The difficulty in diagnosing PV-IE is due to inability to properly visualize the pulmonic valve by echocardiography. In this case, with such large vegetations, transthoracic echocardiography (TTE) allowed a correct diagnosis and an effective surgical planning, confirming its importance as diagnostic tool.

655 The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction

Abstract Aims Recent studies have shown that evolution RL bidirectional rotational mechanical sheath (Cook Medical, USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. Methods and results The study population comprised 84 patients (77% male; mean age 65 ± 18 years) undergoing TLE. After multidisciplinary evaluation, a combined procedure was considered. The main indication for TLE was infection in 54 cases (64%).Overall, 152 leads were extracted with a mean implant duration of 94 ± 63 months (range: 6–421). Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6% (77/84), 97.6% (82/84), and 98.6% (150/152), respectively. Eighteen combined procedures were performed in 12 patients (14%), such as ‘hybrid approach’ (n = 2) or TLE concomitant to: (i) transcatheter aspiration procedure for large vegetation (n = 8); (ii) left ventricular assistance device implantation as bridge to cardiac transplantation (n = 1); (iii) permanent pacing with epicardial leads (n = 6); and (iv) tricuspid valve replacement (n = 1).One major complication (1.2%) and 11 (13%) minor complications were encountered. No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21 ± 18 months, 17 patients (20%) died. They were more often diabetics (P = 0.02), and they underwent TLE more often for infection (P = 0.004). Conclusions Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators.

682. Implantable Cardioverter-Defibrillator Lead Vegetation with Long-Standing Actinomyces neuii Bacteremia

BackgroundEndocarditis caused by Actinomyces species is uncommon with only 30 cases reported in contemporary literature. MethodsWe present a novel case of cardiovascular implantable electronic device (CIED) endocarditis secondary to infection by Actinomyces neuii – a unique non-branching member of the species that grows in both anaerobic and aerobic media.ResultsOur patient, a 51-year-old female, with a history of implantable cardioverter-defibrillator (ICD) placement 17 years prior for heart failure, presented with six weeks of fevers and rigors. She was referred to the infectious disease clinic for evaluation of pyrexia of unknown origin. Her examination was unremarkable, and the ICD pocket was uninflamed. Her initial labs revealed mildly elevated inflammatory markers and renal insufficiency. Blood cultures were positive for slow-growing non-branching gram-positive rods in both aerobic and anaerobic media. These were identified as Actinomyces neuii by mass spectrometry. Review of outside records showed positive blood cultures with Actinomyces neuii at another facility two weeks prior to our evaluation which were not acted upon and thought to be bacterial contamination. The patient was further evaluated with a transesophageal echocardiogram that demonstrated a 3.3 x 2.2cm mobile vegetation attached to the ICD lead. She subsequently underwent removal of her Saint Jude cardiac resynchronization therapy defibrillator and leads using laser and snaring techniques, but the tail end of the ventricular lead fractured and could not be retrieved. The ICD pocket was also found to be infected. A planned 6-week course of IV ampicillin was interrupted by 2 weeks of ceftriaxone for treatment of an intercurrent lower respiratory tract infection. The patient regained her baseline health and was discharged 2 weeks after ICD removal with a LifeVest. She is to complete 12 months of oral amoxicillin therapy after completion of IV antibiotics in view of retained lead fragment, and long standing Actinomyces bacteremia - consistent with published management strategies. Figure 1. Transesophageal echocardiogram demonstrating size of vegetation. Figure 2. Three-dimensional view demonstrating vegetation on the ICD lead.ConclusionHere we describe the first known case of Actinomyces neuii CIED endocarditis with a large lead vegetation and long-standing bacteremia, presenting as pyrexia of unknown origin.Disclosures All Authors: No reported disclosures

Disentangling the roles of land-use-related drivers on vegetation greenness across China

Quantifying the drivers of terrestrial vegetation dynamics is critical for monitoring ecosystem carbon sequestration and bioenergy production. Large scale vegetation dynamics can be observed using the leaf area index (LAI) derived from satellite data as a measure of ‘greenness’. Previous studies have quantified the effects of climate change and carbon dioxide (CO2) fertilization on vegetation greenness. In contrast, the specific roles of land-use-related drivers (LURDs) on vegetation greenness have not been characterized. Here, we combined the Interior-Point Method-optimized ecosystem model and the Bayesian model averaging statistical method to disentangle the roles of LURDs on vegetation greenness in China from 2000 to 2014. Results showed a significant increase in growing season LAI (greening) over 35% of the land area of China, whereas less than 6% of it exhibited a significantly decreasing trend (browning). The overall impact of LURDs on vegetation greenness over the whole country was comparatively low. However, the local effects of LURDs on the greenness trends of some specified areas were considerable due to afforestation and urbanization. Southern Coastal China had the greatest area fractions (35.82% of its corresponding area) of the LURDs effects on greening, following by Southwest China. It was because of these economic regions with great afforestation programs. Afforestation effects could explain 27% of the observed greening trends in the forest area. In contrast, the browning impact caused by urbanization was approximately three times of the greening effects of both climate change and CO2 fertilization on the urban area. And they made the urban area had a 50% decrease in LAI. The effects of residual LURDs only accounted for less than 8% of the corresponding observed greenness changes. Such divergent roles would be valuable for understanding changes in local ecosystem functions and services under global environmental changes.

Abstract 12885: A Challenging Case of Endocarditis— Multi-Disciplinary Approach is an Achievable Chimera

A 60-year-old man with history of coronary artery bypass grafting and mitral valve repair presented with confusion, gait instability and lethargy. Cardiology was consulted after a transthoracic echocardiogram demonstrated a mobile mass on the mitral valve (MV). A subsequent transesophageal echocardiogram showed a large vegetation encompassing and adherent to the anterior annulus and leaflet. Serial blood cultures were negative. The initial differential considered causes of blood culture negative endocarditis (BCNE) with embolic phenomena to the central nervous system. This diagnosis was challenged after the patient developed progressive neurologic symptoms out of proportion to findings on brain imaging. A multidisciplinary team was established to revisit the available data and facilitate a coordinated care approach. The patient was found to fulfill 5 out of 8 criteria for hemophagocytic lymphohistiocytosis (HLH). Furthermore, an H-Score of 268 supported this diagnosis with a >99% probability. Therapy was started with Dexamethasone 5mg/m 2 BID and Anakinra 100mg Q6h, resulting in a rapid improvement in mental status. Secondary HLH in adults is most commonly due to malignancy and infection. Although initial workup was negative, several days into the hospital stay Mycobacterium chimaera was detected on next-generation sequencing of microbial cell-free DNA (Karius test). M. chimaera is a non-tuberculous mycobacterium belonging to the Mycobacterium avium complex and has been associated with a global outbreak following cardiothoracic surgery related to exposure to 3T heater-cooler units (HCU). Endocarditis due to M. chimaera acquired during prior cardiac surgery, complicated by HLH, was considered the most likely unifying diagnosis. This case illustrates: (1) the differential diagnosis of BCNE and the benefit of microbial cell-free DNA testing in its diagnosis, (2) HLH as an unrecognized entity in adults and infectious endocarditis as a possible trigger, (3) the need for improved awareness of M. chimaera infection in patients who have been exposed to HCU presenting with compatible symptoms, and (4) the critical role of communication and a multidisciplinary approach to provide high-quality care in challenging cases such as this one.

Greening at multiple scales promote biodiverse cities: A multi-scale assessment of drivers of Neotropical birds

Biodiversity-sensitive cities can contribute to reconnect humans with nature and halt global biodiversity loss. Achieving biodiversity-sensitive cities is challenging, especially in regions threatened by growing urbanization. To inform urban management and planning in a global biodiversity hotspot, we conducted a multi-scale assessment of drivers of Neotropical birds in the capital city of Santiago de Chile. We investigate the influence of local and landscape variables on native bird species richness and abundance. We surveyed birds and vegetation in 449 sampling points distributed across the city. Native bird species richness was greater in areas with greater shrub and woody vegetation cover at the local scale. Native bird species richness was also greater with high vegetation density in the surrounding landscape and near to an urban boundary. Native birds were abundant in areas with large woody vegetation cover at both local and landscape scales, high vegetation density in the surrounding landscape, near to an urban park and near to an urban boundary. Additive effects of vegetation at different spatial scales suggest that combining local and landscape management, planning and design will be best to preserve native birds in a large city. Although native birds are species rich and abundant near the urban fringe and decrease towards the interior of the city, local-scale management of habitat encouraging shrub and tree planting and landscape-scale actions such as targeting high levels of vegetation (including woody cover) and providing a well-distributed network of urban parks will help sustain native birds across the city. Greening actions at local and landscape-scale will contribute to achieving biodiversity-sensitive cities, providing benefits for people and nature.

Predictors of mortality in patients with left-side infective endocarditis, the ESC-EORP EURO-ENDO registry

Abstract Background/Introduction Infective endocarditis (IE) is associated with high in-hospital mortality, ranging from 16% to 25%, despite improvement in diagnostic and therapeutic strategies, mainly due to complications and heterogeneity of the disease. Baseline risk stratification is essential, in order to focus an aggressive management toward high-risk patients. Purpose We sought to assess the association between surgery and 30-day mortality rate as related to vegetation size. Methods The ESC-EORP EURO-ENDO registry is a prospective multicentre observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Multivariable logistic regression analysis was performed to assess variables associated with 30-day mortality. Besides, univariable analysis was performed to assess best vegetation size cut-off related to 30-day mortality. Results Among 2171 patients with left-side IE, 257 patients (11.8%) died during the first 30 days of IE diagnosis. Patient characteristics and univariable analysis are summarized in TABLE 1. Cut-off value for best vegetation size related to 30-day mortality was vegetation length >14mm, with a HR =2.00 (95% CI 1.59–2.51, p<0.0001) and a Harrell's Concordance of 0.58. After multivariable logistic regression analysis, factors associated with 30-day mortality risk were: vegetation size >14mm (OR =2.68, 95% CI [1.96–3.67], p<0.0001), previous stroke or transient ischemic attack (TIA) (OR =1.60, 95% CI [1.07–2.40], p=0.0235), creatinine >2mg/dL (OR =2.45, 95% CI [1.73–3.47], p<0.0001), presence of embolic events (OR =2.64, 95% CI [1.86–3.74], p<0.0001), hemorrhagic stroke (OR=3.71, 95% CI [1.80–7.64], p=0.0004), presence of heart failure or cardiogenic shock (OR =3.50, 95% CI [2.57–4.77], p<0.0001) and no cardiac surgery during the event (OR =4.07, 95% CI [2.93–5.67], p<0.0001). The C-statistic of the logistic model to predict 30-day mortality was 0.795. Conclusion Left-side infective endocarditis had a high 30-day mortality rate (11.8%). Presence of a large vegetation size (>14mm), embolic events, hemorrhagic stroke, renal failure, presence of heart failure or cardiogenic shock were associated with an increase in 30-day mortality. Performing cardiac surgery had a protective effect. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC-EORP EURO-ENDO project from the ESC society

INFECTED AICD WITH LARGE INTRACARDIAC VEGETATION BURDEN

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis of intracardiac electronic devices is a serious disease process that can have many routes of infectious sources. Patients that have a history of cardiac disease with an electronic intracardiac device present must have endocarditis ruled out when they present with sepsis with multiple sources of infection. When patients are found to have endocarditis with large vegetations on the portions of the device multiple approaches can be performed. We present a case of a 73-year-old male with an infected AICD with large intracardiac vegetations on the atrial portion of the device. CASE PRESENTATION: A 73-year-old male presented to the hospital with septic shock with mental status changes and was found to have urine and blood cultures positive for enterococcus faecalis. The patient had a past medical history of ischemic cardiomyopathy, COVID-19, MRSA urinary tract infections, myocardial infarction, and congestive heart failure. The patient was found to have bilateral pyelonephritis which was thought to be the source of his positive cultures, he was started on IV antibiotics. He underwent transesophageal echocardiogram which showed multiple large mobile heterogenous echogenic masses seen attached to the RV lead prolapsing in the tricuspid valve suggestive of vegetations, largest vegetations > 2.5 cm in size. The patient was taken to the operating room and underwent open removal of the infected AICD on cardiopulmonary bypass. An atriotomy was performed with direct vision of removal of the v lead, a lead, and coronary sinus lead. The vegetations along with the AICD were removed in their entirety. Multiple vegetations were removed with the largest vegetation measuring 3.5 cm. The patient's surgery went well along with the remaining portion of his hospital stay. DISCUSSION: Enterococcus faecalis endocarditis with vegetation formation on AICD leads occurs in less than 4% of cases of infected implantable cardiac devices. Pyelonephritis is often a complication from embolic sources from the endocarditis or can be the initial source of infection. All sources of infection must be accounted for when patients are found to have vegetations on TEE. Multiple studies have shown that larger vegetations result in higher morbidity and mortality. CONCLUSIONS: When patients are found to have large vegetations greater than 2.5 cm connected to their implantable cardiac electronic devices or valves early surgical removal of the infected device should be considered to reduce morbidity and mortality for the patient. Large vegetations should be removed using an open technique so the risk of the vegetative mass becoming dislodged and causing a main stem pulmonary embolism can be greatly reduced. REFERENCE #1: Guillermo V. Brazilain Journal of Cardiovascular Surgery- Pacemaker endocarditis with lead extraction for large vegetations, Dec 2009 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response

A RARE CASE OF RIGHT-SIDED TRICUSPID VALVE ENDOCARDITIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Right-sided endocarditis is a well-known condition that occurs predominantly in intravenous drug users (IVDA) and patients with cardiovascular implantable electronic devices, central venous lines, and congenital heart disease. The objective of this report is to describe a rare case of right-sided endocarditis that leads to cardiogenic shock and death. CASE PRESENTATION: A 29-year-old caucasian male with a history of polysubstance abuse, acromioclavicular joint septic arthritis, status epilepticus secondary to cerebral septic emboli, presented to the emergency department with complaints of shortness of breath, generalized weakness, and malaise. He was noted to have significant respiratory distress requiring initially noninvasive mechanical ventilation, he was intubated due to worsening respiratory failure. Cardiovascular examination revealed a pansystolic murmur heard over the left parasternal border. Transthoracic echocardiogram showed severe tricuspid valve regurgitation and moderately dilated right ventricle with an ejection fraction of 63%. A transesophageal echocardiogram revealed severe 3+ to 4+ tricuspid valve regurgitation along with large vegetation on the anterior leaflet of the tricuspid valve measuring 2.2 cm x 0.8 cm. There is the involvement of the subvalvular apparatus with another large vegetation measuring 1.1 cm x 0.8 cm on the chordal apparatus (FIGURE 1). The patient was found to be in cardiogenic versus septic shock related to tricuspid valve recurrent infective endocarditis. Despite the patient being placed on intravenous antibiotics and two pressors he still continued to deteriorate. Discussion with the family decided to make the patient comfort-care. The patient ultimately expired. DISCUSSION: Right-sided infective endocarditis (RSIE) patients represent 5-10% of all infective endocarditis cases, making it a rare clinical entity. It is most commonly seen in patients with a history of IVDA; however, it is also seen in patients on dialysis, congenital heart disease, immunocompromised states patients, and patients who have an intracardiac device. The diagnosis of RSIE is often delayed due to its signs and symptoms relatively different than left-sided infective endocarditis which is the specific target of the modified duke's criteria. Common symptoms include cough, hemoptysis, dyspnea, chest pain, and persistent fever. The primary diagnostic modalities are echocardiography and positive blood cultures. The mainstay of medical treatment is antibiotics; however if refractory then surgery is indicated in cases of right-sided heart failure due to severe tricuspid regurgitation, persistent bacteremia, refractory to culture-directed antibiotics, and tricuspid valve vegetations greater than 20 mm in length. CONCLUSIONS: Clinicians should be aware of the variety of presentations a patient with suspected endocarditis could have as disease prognosis relies on a prompt diagnosis. REFERENCE #1: Narvaez Muñoz Adrian Fernando, Ibarra Vargas Daniela Albina. Right-Sided Infective Endocarditis, Infective Endocarditis, Peter Magnusson and Robin Razmi. IntechOpen. March 24th 2019 REFERENCE #2: Varona J., Guerra J. Tricuspid Valve Endocarditis in a Nonaddicted Patient Without Predisposing Myocardiopathy. Revista Española De Cardiología (English Edition) 2004;57(10):993–996. REFERENCE #3: Ye R., Zhao L., Wang C., Wu X., Yan H. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. 2014;108(1):1–8. DISCLOSURES: No relevant relationships by Adeeb Alquthami, source=Web Response No relevant relationships by Nishad Barve, source=Web Response No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by NICOLE LAO, source=Web Response No relevant relationships by Gauranga Mahalwar, source=Web Response

AN UNUSUAL CASE OF INFECTIVE ENDOCARDITIS PRESENTING AS MENINGOCOCCAL MENINGITIS IN A YOUNG MALE WITH RECENT DENTAL WORK

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Incidence of infective endocarditis (IE) has been increasing in U.S., likely due to increased age, valvular diseases and cardiac device implantation or valve replacements. Here, we present a case of infective endocarditis with uncommon presentation, unusual risk factors and rapidly progressing course that is important for clinicians to consider in their clinical practice. CASE PRESENTATION: A 39-year-old healthy man, without smoking or drug use, presented for altered mental status and fever for 1-2 days. His initial vitals were significant for a temperature of 103.8˚F. On exam, he was oriented x2, had conjunctival petechiae, a fixed dental expander, a soft systolic murmur and petechial rash over his body. CSF studies suggested bacterial meningitis, but gram stain was negative. CT head showed a subarachnoid hemorrhage. He was started on ceftriaxone, vancomycin and steroids for likely meningococcal meningitis. His blood cultures grew methicillin sensitive Staphylococcus aureus. He developed atrial fibrillation with rapid ventricular response and elevation in troponin to 41.26 ng/dL. A transthoracic echocardiogram showed a stenotic aortic valve suggestive of bicuspid valve without vegetations. CT chest/abdomen/pelvis showed infarcts within the spleen, kidneys and mesentery. His clinical condition further declined and EKG revealed a prolonged P-R interval. A transesophageal echocardiogram showed a large aortic valve vegetation and aortic root abscess. Cardiothoracic surgery was consulted for early surgical intervention with abscess drainage and aortic valve replacement. Patient was successfully discharged home with antibiotics and warfarin. DISCUSSION: The initial presentation of fever, malaise, altered mental status and petechial rash in a young person was suspicion for meningococcal meningitis. One study of patients with IE showed 6% had encephalopathy/meningitis and 4% had hemorrhages. These complications were seen particularly with vegetations ≥3cm and S. aureus infections, similar to this patient. It is imperative to have high suspicion for IE in any infected patient with generalized CNS symptoms. Our patient lacked known risk factors for IE, thus a detailed physical examination is paramount in patients with a high index of suspicion. Presence of a dental implant provided us the initial clue towards this key diagnosis. Few studies show causation of dental procedures and risk of developing IE. This is another rare example. We report successful treatment of a rapidly progressive disease with early diagnosis, appropriate antibiotics and early surgical intervention. CONCLUSIONS: A high index of suspicion is required to quickly diagnosis IE. A detailed physical examination is paramount for correct diagnosis. TEE is superior to bedside TTE in such cases. IE can be complicated with intracardiac abscesses, septic shock, and presence of SAH. REFERENCE #1: Sexton, Daniel, and Vivian Chu. "Native Valve Endocarditis: Epidemiology, Risk Factors, and Microbiology." UpToDate, 7 Oct. 2020, www.uptodate.com/contents/native-valve-endocarditis-epidemiology-risk-factors-and-microbiology?search=causes+of+enodcarditis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. REFERENCE #2: Thanavaro, Kristin L., and J.V. (Ian) Nixon. "Endocarditis 2014: An Update." Heart & Lung, Mosby, 26 Apr. 2014, www.sciencedirect.com/science/article/pii/S0147956314000788. REFERENCE #3: McDonald, Jay R. "Acute Infective Endocarditis." Infectious Disease Clinics of North America, U.S. National Library of Medicine, Sept. 2009, www.ncbi.nlm.nih.gov/pmc/articles/PMC2726828/. DISCLOSURES: No relevant relationships by Michelle Zur, source=Web Response