Left-sided Native Valve Research Articles

P-1803. Why We Do What We Do: A Survey of ID Providers About Oral Antibiotics

Abstract Background Multiple studies have shown the efficacy of oral antibiotics for serious infections. Despite this, many infectious disease (ID) providers continue to solely use intravenous (IV) antibiotics. To understand current practices among ID providers in our healthcare system, we conducted a survey to observe practice patterns, comfort level, and beliefs around oral antibiotics.Table 1.Respondent Demographics and Responses Methods Our survey was distributed via email to 137 local ID providers at nine hospitals. The survey included questions about demographics, practice characteristics, and comfort with as well as barriers to prescribing oral antibiotics. Also included were five clinical cases for which respondents were asked to choose definitive therapy from a selection of IV and oral options. Based on responses, providers were classified as either high- or low-oral antibiotic prescribers (HOAP or LOAP). Categorical variables were analyzed using chi-square or Fischer’s exact test as appropriate.Table 2.Respondent Answers to Clinical Cases Results A total of 60 clinicians (44%) completed our survey. 87% were academic affiliated (52/60), while 13.3% (8/60) identified as private practice (Table 1). Half of respondents were categorized as LOAP. All respondents chose an oral step-down therapy for a case of E. coli bacteremia, while only one provider chose an oral option for step-down therapy for left-sided native valve endocarditis caused by E. faecalis (Table 2). 73.3% of HOAP chose oral antibiotics as definitive therapy for the case of an uncomplicated MSSA central line associated bloodstream infection compared to no LOAP (Table 2). The only statistically significant predictor of LOAP was type of practice; with all private practice providers classified as LOAP. HOAP were more likely to cite supervisor concerns with oral antibiotics as a barrier to prescribing oral antibiotics. Interestingly, similar numbers of HOAP and LOAP expressed they had no concerns about prescribing oral antibiotics. Conclusion In this survey of ID providers regarding oral antibiotics, most demographics did not predict HOAP or LOAP. Certain clinical scenarios, such as Gram-negative bacteremia, led to oral antibiotic use in both LOAP and HOAP. This information can be used by stewardship programs to target interventions to encourage oral antibiotic step-down therapy in LOAP. Disclosures Marisa Winkler, MD, PhD, Element Iowa City (JMI Laboratories) was contracted to perform services in 2023 for > 30 biotech and pharmaceutical companies: Grant/Research Support

Which trial do we need? A randomized controlled trial comparing oral antibiotic monotherapy versus standard of care as antibiotic continuation treatment for the treatment of left-sided native valve bacterial endocarditis

Which trial do we need? A randomized controlled trial comparing oral antibiotic monotherapy versus standard of care as antibiotic continuation treatment for the treatment of left-sided native valve bacterial endocarditis

Echocardiographic findings and subsequent risk of native valve endocarditis

Aim: The association of echocardiographic findings and subsequent risk of left-sided native valve endocarditis (LS-NVE) is undefined. The aim of this study was to determine if transthoracic echocardiography (TTE) measurements are associated with the subsequent development of LS-NVE in patients without cardiac predisposing conditions. Methods: Institutional databases were evaluated for adults diagnosed with LS-NVE from 2008 to 2020. Patients with prosthetic valves, cardiovascular implantable electronic devices, intracardiac devices, injection drug use, and predisposing cardiac conditions were excluded. Only patients who had a TTE performed 6 months to 3 years before the development of LS-NVE were included as cases. Controls were patients within the same Mayo location with a TTE report and were matched in a 1:3 ratio according to age, gender, Charlson comorbidity index, and echocardiography date. Results: There were 148 cases and 431 matched controls. As compared to controls, infective endocarditis (IE) cases had a higher prevalence of diabetes mellitus (46.6% vs. 30.4%) and chronic kidney disease (46.6% vs. 28.1%) (P < 0.001). Left ventricular outflow tract velocity (P = 0.017), left ventricular ejection fraction (P = 0.018), and E:e’ ratio (P = 0.050) were associated with LS-NVE. Conclusions: Echocardiographic measurements were associated with subsequent LS-NVE development in this pilot study. A larger cohort of LS-NVE patients, however, is needed to validate these findings.

Trends of Infective Endocarditis at Two Teaching Hospitals: A 12-Year Retrospective Cohort Study in Rio de Janeiro, Brazil.

Despite advances in diagnosis and treatment, the incidence and mortality of infective endocarditis (IE) have increased in recent decades. Studies on the risk factors for mortality in endocarditis in Latin America are scarce. This retrospective cohort study included 240 patients diagnosed with IE according to the modified Duke criteria who were admitted to two university hospitals in Rio de Janeiro, Brazil from January 2009 to June 2021. Poisson regression analysis was performed for trend tests. The multivariate Cox proportional hazards model was used to estimate the hazard ratio (HR) of predictors of in-hospital mortality. The median age was 55 years (IQR: 39-66 years), 57% were male, and 41% had a Charlson comorbidity index (CCI) score > 3. Healthcare-associated infective endocarditis (54%), left-sided native valve IE (77.5%), and staphylococcal IE (26%) predominated. Overall, in-hospital mortality was 45.8%, and mortality was significantly higher in the following patients: aged ≥ 60 years (53%), CCI score ≥ 3 (60%), healthcare-associated infective endocarditis (HAIE) (53%), left-sided IE (51%), and enterococcal IE (67%). Poisson regression analysis showed no trend in in-hospital mortality per year. The adjusted multivariate model determined that age ≥ 60 years was an independent risk factor for in-hospital mortality (HR = 1.9; 95% CI 1.2-3.1; p = 0.008). In this 12-year retrospective cohort, there was no evidence of an improvement in survival in patients with IE. Since older age is a risk factor for mortality, consensus is needed for the management of IE in this group of patients.

Left-sided native valve infective endocarditis concomitant with severe valvular regurgitation: Prevalence, characteristics and prognostic factors

Abstract Background The characteristics of patients with left-sided native valve infective endocarditis and severe valvular regurgitation has never been studied. Purpose To analyze the prevalence of severe valvular regurgitation in patients with left-sided infective endocarditis, to describe in detail their characteristics and to determine the prognostic factors of these patients. Patients and methods We included in an ongoing multipurpose database, all patients with definite left-sided infective endocarditis admitted in three Spanish tertiary hospitals from 2005 to 2022. We describe the clinical, epidemiological, microbiological, echocardiographic characteristics of patients with severe valvular regurgitation and compared it with those without it. We also analyzed the independent factors of in-hospital mortality of these patients. Results Of a total of 874 patients with left-sided native valve infective endocarditis of our series, 564 had severe valvular regurgitation (65%). Comparison between patients with and without severe valvular regurgitation is shown in figure 1. Age (HR 1.035 95% CI 1.02-1.05), S. aureus (HR 2.26; 95% CI 1.26-4.1), vegetations (HR 3.7; 95% CI 1.2-11.4), heart failure (HR 2.76; 95% IC 1.5-5.1), renal failure (HR 3.1; 95% CI 1.9-4.9) and septic shock (HR 4.3; 95% CI 2.29-8) were the independent factors of in hospital mortality. On the contrary, cardiac surgery is an independent protector factor of mortality (HR 0.35; 95% CI 0.21-0.59). Conclusions A very high proportion of patients with definite left-sided infective endocarditis have severe valvular regurgitation in our series. Despite important epidemiological, clinical and echocardiographic differences with patients without it, the short-term prognosis is similar Surgery is an independent protective factor in these patients.

Abstract 12875: Echocardiographic Findings Associated With Subsequent Risk of Native Valve Endocarditis

Introduction: The association of echocardiographic measurements and subsequent risk of left-sided native valve endocarditis (LS-NVE) is undefined. Aim: To determine if transthoracic echocardiographic (TTE) measurements are associated with the subsequent development of LS-NVE in patients without recognized cardiac predisposing conditions. Methods: Institutional databases were evaluated for adults diagnosed with LS-NVE from 2008 to 2020. Patients with prosthetic valves, cardiovascular implantable electronic devices, intracardiac devices, injection drug use, and recognized predisposing cardiac conditions were excluded. Patients with a TTE performed 6 months to 3 years before developing LS-NVE were included as cases. Controls were patients within the same Mayo Clinic location with a TTE report and were matched in a 1:3 ratio according to age, gender, Charlson Comorbidity Index (CCI), and echocardiography date. Multivariate logistic-regression analyses adjusting significant variables between cohort's were performed. A p-value <0.05 was considered significant. Results: There were 148 cases and 431 matched controls. The median age was 63.8 (IQR: 53.6 - 74.6) years, and 329 (56.8%) patients were males. LS-NVE cases had a higher prevalence of diabetes mellitus (46.6% vs. 30.4%) and chronic kidney disease (46.6% vs. 28.1%) when compared with controls (p<0.001 both). The median CCI score was 3 (IQR: 0-6) for cases and 2 (IQR: 0-6) for controls. After performing adjusted analyses, left ventricular outflow tract velocity (p=0.017), left ventricular ejection fraction (p=0.018), and E: e’ ratio (p=0.050) were associated with the development of LS-NVE ( Figure 1) . Conclusions: Echocardiographic measurements were associated with subsequent LS-NVE development in this preliminary investigation. A larger cohort of LS-NVE patients is needed to validate these findings.

Splenic Artery Infectious Aneurysms in Infective Endocarditis – An Observational Study and Comprehensive Literature Review

PurposeTo determine the prevalence, the clinical and radiological features, associated factors, treatment and outcome of splenic artery aneurysms (SAAs) in infective endocarditis (IE). MethodsWe retrospectively reviewed 474 consecutive patients admitted to our institution with definite IE (2005-2020) ResultsSix patients had SAAs (1.3%; 3 women; mean age: 50). In all cases the diagnosis was obtained by abdominal CT-angiography (CTA). SAAs-IE were solitary, saccular with a mean diameter of 30mm (range: 10-90mm). SAAs-IE were intrasplenic (n=4) or hilar (n=2). Streptococcus spp were the predominant organisms (n=4).In all cases a left-sided native valve was involved (aortic, n=3; mitral, n=2, mitral-aortic, n=1). SAAs were silent in half-patients, and were revealed by abdominal pain (n=2) and by the resurgence of fever after cardiac surgery (n=1).All patients underwent emergent valve replacement. One patient died within 24h from multiorgan failure. For the others, uneventful coil embolization was performed in 4 patients after valve replacement (3 diagnosed early, one at 8 weeks). In the remaining patients, SAA-IE diagnosed at abdominal-CTA at day 16, with complete resolution under appropriate antibiotherapy alone. ConclusionSAAs-IE are a rare occurrence that may be clinically silent. SAAs-IE can be intrasplenic or hilar in location. Endovascular treatment in this context was safe. According to current guidelines, radiologic screening by abdominal-CTA allowed the detection of silent SAAs which could be managed by endovascular treatment to prevent rupture. The delayed formation of these SAAs could justify a CTA control at the end of antibiotherapy.

Contemporary Clinical Profile of Left-Sided Native Valve Infective Endocarditis: Influence of the Causative Microorganism.

Studies focused on the clinical profile of native valve endocarditis are scarce and outdated. In addition, none of them analyzed differences depending on the causative microorganism. Our objectives are to describe the clinical profile at admission of patients with left-sided native valve infective endocarditis in a contemporary wide series of patients and to compare them among the most frequent etiologies. To do so, we conducted a prospective, observational cohort study including 569 patients with native left-sided endocarditis enrolled from 2006 to 2019. We describe the modes of presentation and the symptoms and signs at admission of these patients and compare them among the five more frequent microbiological etiologies. Coagulase-negative Staphylococci and Enterococci endocarditis patients were the oldest (71 ± 11 years), and episodes caused by Streptococci viridans were less frequently nosocomial (4%). The neurologic, cutaneous or renal modes of presentation were more typical in Staphylococcus aureus endocarditis (28%, p = 0.002), the wasting syndrome of Streptococcus viridans (49%, p < 0.001), and the cardiac in Coagulase-negative Staphylococci, Enterococci and unidentified microorganism endocarditis (45%, 49% and 56%, p < 0.001). The clinical signs agreed with the mode of presentation. In conclusion, the modes of presentation and the clinical picture at admission were tightly associated with the causative microorganism in patients with left-sided native valve endocarditis.

Does Perivalvular Involvement Affect the Long-Term Surgical Outcomes of Primary Left-Sided Endocarditis?

Surgical treatment of infective endocarditis (IE) remains challenging, especially in cases of perivalvular destruction and poor clinical presentation. We evaluated the outcomes of surgery for simple (isolated leaflet involvement) versus complex (perivalvular involvement) primary left-sided native valve endocarditis. From 2005 to 2019, a total of 128 consecutive patients (age 57.7 ± 14.2 years) with IE were surgically managed. Study end points were operative and late mortality and freedom from recurrent infection and reoperation for recurrent endocarditis. Patients were categorized as having simple IE (n = 91) versus complex IE (n = 37) based on the preoperative imaging and/or intraoperative findings. Valves involved were aortic in 39% (n = 50), mitral in 46% (n = 59), or both (11%, n = 14). The operative mortality was 11.7% (n = 15), and 9 of them (60%) presented with shock or multiorgan failure. A critical preoperative state was the only independent risk factor for early mortality (odds ratio 7.43, p <0.01). The overall survival was 81.9%, 74.8%, 58%, and 52% at 1, 5, 10, and 15 years, respectively. Long-term survival was similar between simple and complex groups (p = 0.29). Chronic renal failure was the only independent risk factor for late mortality (hazard ratio 2.44, p = 0.02). Freedom from re-endocarditis was 95.2%. None of the patients underwent reoperation because of recurrent endocarditis. Mitral valve repair was performed in 30.7% of all cases with mitral valve involvement. None of them had significant mitral regurgitation or recurrent endocarditis on follow-up. In conclusion, surgery for IE in the setting of complex perivalvular involvement is associated with a low rate of recurrent endocarditis or reoperation and comparable long-term survival to patients with isolated leaflet involvement. Mitral valve repair was feasible and durable in a significant proportion of patients even in the presence of endocarditis.

Single-Centre Retrospective Evaluation of Intraoperative Hemoadsorption in Left-Sided Acute Infective Endocarditis.

Background: Cardiac surgery in patients with infective endocarditis (IE) is still associated with high mortality and morbidity; an already present inflammation might further be aggravated due to a cardiopulmonary bypass-induced dysregulated immune response. Intraoperative hemoadsorption therapy may attenuate this septic response. Our objective was therefore to assess the efficacy of intraoperative hemoadsorption in active left-sided native- and prosthetic infective endocarditis. Methods: Consecutive high-risk patients with active left-sided infective endocarditis were enrolled between January 2015 and April 2021. Patients with intraoperative hemoadsorption (Cytosorbents, Princeton, NJ, USA) were compared to patients without hemoadsorption (control). Endpoints were the incidence of postoperative sepsis, sepsis-associated death and in-hospital mortality. Predictors for sepsis-associated mortality and in-hospital mortality were analysed by multivariable logistic regression. Results: A total of 202 patients were included, 135 with active left-sided native and 67 with prosthetic valve infective endocarditis. Ninety-nine patients received intraoperative hemoadsorption and 103 patients did not. Ninety-nine propensity-matched pairs were selected for final analyses. Postoperative sepsis and sepsis-related mortality was reduced in the hemoadsorption group (22.2% vs. 39.4%, p = 0.014 and 8.1% vs. 22.2%, p = 0.01, respectively). In-hospital mortality tended to be lower in the hemoadsorption group (14.1% vs. 26.3%, p = 0.052). Key predictors for sepsis-associated mortality and in-hospital mortality were preoperative inotropic support, lactate-levels 24 h after surgery, C-reactive protein levels on postoperative day 1, chest tube output, cumulative inotropes and white blood cell counts on postoperative day 2, and new onset of dialysis. Multivariate regression analysis revealed intraoperative hemoadsorption to be associated with lower sepsis-associated (OR 0.09, 95% CI 0.013–0.62, p = 0.014) as well as in-hospital mortality (OR 0.069, 95% CI 0.006–0.795, p = 0.032). Conclusions: Intraoperative hemoadsorption holds promise to reduce sepsis and sepsis-associated mortality after cardiac surgery for active left-sided native and prosthetic valve infective endocarditis.

Prosthesis choice for surgical treatment of left-sided native valve infective endocarditis: Determinants and impact on outcomes

Surgical treatment is required in approximately half of the patients with infective endocarditis (IE) because of severe complications. To date there is no recommendation favoring a specific valve substitute for IE treatment and accordingly there is a wide variation in routine surgical management of these patients. The purpose of this study is to describe surgical practices in our center and to investigate the impact on clinical outcomes. All patients with native valve left-sided IE, who underwent valve replacement surgery with a mechanical or biological prosthesis in our institution between 1 January 2006 and 31 December 2018 were enrolled in this retrospective study. A total of 303 patients were included (mean age = 58 years, 80% men). Patients in whom a biological valve was chosen (64%, n = 194) were older and had more comorbid conditions compared to patients who received a mechanical valve (36%, n = 109). In hospital mortality was respectively 19% ( n = 36) in the bioprosthesis group avec 3% ( n = 3) in the mechanical valve group ( P < 0.0001). The mortality rates at 1 and 3 years were 35% and 41% in the biological valve group, these rates were 8% and 15% in the mechanical valve group. Factors associated to in hospital and mid term mortality were age, comorbid conditions, hemodynamic failure, a double valve replacement or associated bypass surgery. The type of the implanted valve substitute was not independently associated with mortality. For surgical management of IE, a biological valve is the most used valve substitute in our institution. Mechanical valves seem to be implanted in a very selected and low-risk patient subgroup. The valve substitute does not appear to be related to in hospital nor to midterm mortality rates.

Can prosthesis type influence the recurrence of infective endocarditis after surgery for native valve endocarditis? A propensity weighted comparison.

Our goal was to investigate whether the incidence of valve-related adverse events might be different depending on the valve substitute after valve replacement for left-sided native valve endocarditis. We assessed the long-term freedom from recurrence, reoperation and survival of 395 patients who had valve replacements for native valve endocarditis (314 mechanical vs 81 biological). Age <18 years, reoperation, prosthetic endocarditis, right valve involvement, valve repair and homograft implants were the main exclusion criteria. The balance between the 2 groups was addressed by weighting the results on the inverse of the propensity score. After inverse probability of treatment weighting (IPTW), freedom from recurrence of infective endocarditis was not significantly different (mechanical 84.1 ± 3.2% vs 50.6 ± 21.7%; P = 0.29) nor was freedom from reoperation different (mechanical 85.7 ± 3.1% vs biological 50.9 ± 21.9%; P = 0.29). Excluding competing deaths, patients receiving a bioprosthesis had a similar subdistribution hazard of the above end points compared to recipients of a mechanical valve [recurrence IPTW: hazard ratio (HR) 1.631, 95% confidence interval (CI) 0.756-3.516; P = 0.21; reoperation IPTW-HR 1.737, 95% CI 0.780-3.870; P = 0.18]. Mechanical valves were associated with improved long-term survival (34.9 ± 5.8% vs 10.5 ± 7.4% at 30 years; P = 0.0009; in particular: aortic valve subgroup 41.6 ± 9.3% vs 10.1 ± 8.2%; P < 0.0001), although the hazard of cardiovascular mortality did not favour either valve type (IPTW: HR 1.361, 95% CI 0.771-2.404; P = 0.29). Our analysis showed a clinical trend in favour of mechanical valves as valve substitutes for native valve endocarditis, especially in the aortic position. In view of long-term freedom from adverse events, the choice of the valve type should be tailored according to patient characteristics and specific clinical conditions.

Congestive heart failure in endocarditis: Prevalence, clinical characteristics and outcome

Heart failure (HF) is the most common complication of infective endocarditis. Not only that, it represents one of the major causes of deaths in native valve infective endocarditis. Consequently, CHF is currently the main indication for early surgery in IE. This single-center study aims to assess to determine prevalence, clinical characteristics and to identify prognostic factors in patients with left-sided native valve IE complicated by congestive heart failure. Therefore, we conducted a retrospective study between December 2013 and September 2019. Patients with possible or definite infective endocarditis according to the European society of cardiology modified Duke Criteria (2015) were included in the study. Baseline clinical, echocardiographic characteristics and previous history of the patients were obtained from the hospital records. In total, 114 consecutive patients with definite left-sided native valve IE according to the Duke criteria were included in this analysis. Seventy patients (61%) presented a congestive heart failure at admission or during hospitalization. Comparing the patients with CHF to without CHF, new heart murmur, aortic valve vegetations and severe mitral or aortic regurgitation were more associated with congestive heart failure ( P = 0.04/ P = 0.005/ P = 0.034). Congestive heart failure was independently predictive of in-hospital mortality [OR: 4.2 (2.4–7.0)]. In-hospital mortality was 21.4% for the entire HF cohort, with lower mortality observed in patients undergoing valvular surgery compared with medical therapy alone (13.4% vs. 44.4%, respectively; P < 0.05). Left-sided native valve IE complicated by CHF is more frequent in aortic IE and is associated with severe regurgitation. In CHF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.

Characteristics and Prognosis of Patients With Left-Sided Native Bivalvular Infective Endocarditis

BackgroundMost cases of left-sided native valve infective endocarditis (IE) involve a single valve and little is known concerning IE that simultaneously affects the aortic and mitral valves. MethodsWe aimed to determine the characteristics, identify the prognostic factors, and define the effect of early surgery for patients with left-sided native bivalvular IE. This analysis included 1340 consecutive patients who presented with definite acute left-sided native valve IE in a 2-centre cohort study. ResultsA bivalvular involvement was present in 257 patients (19%). Patients with bivalvular IE had more embolic events (P = 0.044), congestive heart failure (P = 0.016), vegetations, and perivalvular complications (both P < 0.001) than those with monovalvular IE. Early surgery was more frequent for patients with bivalvular IE (P < 0.001). Thirty-day mortality was higher for patients with bivalvular IE than for those with monovalvular IE (24.5% vs 17.6%; P = 0.008), even after adjustment (odds ratio, 1.86 [95% confidence interval, 1.26-2.73]; P < 0.001). Estimated 10-year survival was 70% ± 1% for monovalvular IE and 59% ± 3% for bivalvular IE (P = 0.002). Bivalvular IE was still associated with mortality in multivariable Cox analysis, after adjustment for covariates including age, neurological events, congestive heart failure, Staphylococcus spp infection, perivalvular complications, and early surgery (hazard ratio, 1.70 [95% confidence interval, 1.31-2.11]; P < 0.001). Early surgery was associated with increased survival for patients with bivalvular IE (79% ± 4% vs 35% ± 6%; P < 0.001). ConclusionsBivalvular involvement is frequent in left-sided native valve IE, is associated with more embolic events and congestive heart failure than monovalvular IE, and patients are at a high risk of death. Early surgery is associated with improved survival and should be systematically discussed in the absence of contraindication.

Elderly versus non-elderly patients undergoing surgery for left-sided native valve infective endocarditis: A 10-year institutional experience

This retrospective study aimed to clarify the short- and mid-term outcomes of elderly patients who underwent surgery to treat left-sided native valve infective endocarditis (LSNIE). Between July 2005 and September 2015, 179 patients underwent surgical treatment for active LSNIE at a single institution. Patients were classified into two groups: ≥65 years (elderly group) and <65 years (non-elderly group). Clinical features, surgical information, postoperative complications, and three-year survival rates were compared. The average ages were 74.2 ± 6.4 and 45.2 ± 12.6 years in the elderly and non-elderly groups, respectively. The elderly group had a higher predicted mortality rate and a lower incidence of preoperative septic emboli-related complications. Echocardiographic assessments of infected valves were generally homogenous between the groups. The elderly patients had a higher in-hospital mortality rate than the non-elderly patients (26.3% vs. 5.7%, P = 0.001). For patients who survived to discharge, the three-year cumulative survival rates were 75.0% ± 8.2% and 81.2% ± 3.4% in the elderly and non-elderly groups, respectively (P = 0.484). In conclusion, elderly patients are at a higher risk of in-hospital mortality after surgery for LSNIE. However, once elderly patients are stabilized by surgical treatment and survive to discharge, the mid-term outcomes are promising.

472 Epidemiology and temporal trends of cardiac device related infective endocarditis

Abstract Background Infective endocarditis (IE) is a rare, but life-threatening complication of cardiac device implantation. Despite recent preventive strategies, and advances in antimicrobial and surgical treatment, morbidity and mortality rates are still high. Aims The objective of our study was to assess the epidemiological characteristics, temporal tends and mortality rate of cardiac device related IE (CDRIE) in our high-volume, tertiary referral center. Methods retrospective data collection was performed from January 1, 2006 to December 31, 2016. Thirty-day, 6-month and 1-year mortality was estimated, which were compared to left-sided native valve endocarditis (LSNIE). Patients administered between 2006 and 2010 and between 2011 and 2016 were compared to assess temporal trends. Results 465 cases of IE were administered, out of whom 54 patients had CDRIE (39 males [72%], mean age: 55.8 ±19 yrs; 4 VVI, 7 VDD, 7 VVI-ICD, 20 DDD, 5 DDD-ICD and 11 CRT devices; median time since first implantation: 1558 days [IQR: 470 days – 8.6 yrs]). The infection was caused by streptococci in 3 cases (5.5%), Staphylococci were the most prevalent infective agents (70%), S. aureus (SA) in 28 cases (52%, out of whom 10 were MRSA), coagulase negative Staphylococcus in 10 cases (18.5%), blood culture negative cases in 8 patients (15%), and in 5 cases other pathogens were responsible. 266 patients had LSNIE (201 males [75%], mean age: 54.4 ± 15.6 yrs). There was no difference between the two groups in age or in portion of males. Mortality rates were the same in CDRIE group compared to LSNIE group (30-day: 13% vs 13%, 6-month: 20% vs 25%, 1-year: 26% vs 29% and long-term: 44% vs 44%, ns resp.) Patients who died in the CDRIE group (n = 25) were older (64 yrs [IQR:59-71 yrs] vs 52 yrs [IQR: 27-69 yrs], p = 0.02), male sex was less common (52% vs 79%, p = 0.03), had lower ejection fraction (39.6 ±16.6% vs 54.6 ±14.5%, p &amp;lt; 0.001), had worse renal function (GFR: 46.3 ± 15.3 vs 60.2 ± 23.5 ml/min/1.73m2, p = 0.04), shorter time since first device implantation (2.1 yrs [IQR: 1.1-4.8 yrs] vs 6.7 yrs [4.1-12.9 yrs], p = 0.006), and CRT device implantation were more prevalent (32% vs 10%, p &amp;lt; 0.05). Patients admitted before 2011 (n = 22) did not differ from patients admitted after 2011 (n = 32) in terms of age, male gender, concomitant valve infection, pocket infection, or embolic event. The 30-day (0% vs 6%) and the 1-year mortality (18% vs 31%) were the same before and after 2011, but the 6-month mortality was better before 2011 (4.5% vs 31%, p = 0.01). CRT device implantation was more prevalent over time (5% vs 31%, p = 0.01), and SA infection became more frequent (36% vs 63%, p = 0.05) Conclusions During the last decade patients with CDRIE had a same survival as patients with LSNIE, every fourth patient died one year after the diagnosis. Almost three-quarter of the infections were caused by Staphylococci, and the portion of S. aureus infection increased over time.

Valve regurgitation in patients surviving endocarditis and the subsequent risk of heart failure

BackgroundSignificant valve regurgitation is common in patients surviving native valve infective endocarditis (IE), however the associated risk of heart failure (HF) subsequent to hospital discharge after IE is sparsely described.MethodsWe...

The changing landscape of infective endocarditis in South Africa.

Little is known about the current clinical profile and outcomes of patients with infective endocarditis (IE) in South Africa (SA). To provide a contemporary and descriptive overview of IE in a representative SA tertiary centre. We conducted a retrospective review of the records of patients admitted to Groote Schuur Hospital, Cape Town, between 2009 and 2016 fulfilling universal criteria for definite or possible IE, in search of demographic, clinical, microbiological, echocardiographic, treatment and outcome information. A total of 105 patients fulfilled the modified Duke criteria for IE. The median age of the cohort was 39 years (interquartile range (IQR) 29 - 51), with a male preponderance (61.9%). The majority of the patients (72.4%) had left-sided native valve endocarditis, 14.3% had right-sided disease, and 13.3% had prosthetic valve endocarditis. A third of the cohort had rheumatic heart disease. Although 41.1% of patients with left-sided disease had negative blood cultures, the three most common organisms cultured in this subgroup were Staphylococcus aureus (18.9%), Streptococcus spp. (16.7%) and Enterococcus spp. (6.7%). Participants with right-sided endocarditis were younger (29 years, IQR 27 - 37) and were mainly intravenous drug users (73.3%), and the majority cultured positive for S. aureus (73.3%) with frequent septic pulmonary complications (40.0%). The overall in-hospital mortality was 16.2%, with no deaths in the group with right-sided endocarditis. Predictors of death in our patients were heart failure (odds ratio (OR) 8.16, 95% confidence interval (CI) 1.77 - 37.70; p=0.007) and age &gt;45 years (OR 4.73, 95% CI 1.11 - 20.14; p=0.036). Valve surgery was associated with a reduction in mortality (OR 0.09, 95% CI 0.02 - 0.43; p=0.001). IE remains an important clinical problem in a typical teaching tertiary care centre in SA. In this setting, it continues to affect mainly young people with post-inflammatory valve disease and congenital heart disease. The in-hospital mortality associated with IE remains high. Intravenous drug-associated endocarditis caused by S. aureus is an important IE subset, comprising ~10% of all cases, which was not reported 15 years ago, and culture-negative endocarditis remains highly prevalent. Heart failure in IE carries a significant risk of death and needs a more intensive level of care in hospital. Finally, cardiac surgery was associated with reduced mortality, with the largest impact in patients with heart failure.

Early transthoracic echocardiography has useful prognostic value in left-sided native valve endocarditis despite limited diagnostic performance.

To investigate the prognostic implications of findings on early transthoracic echocardiography (TTE) in patients with definite left-sided native valveinfective endocarditis (LNVIE). We reviewed a 10-year retrospective cohort of consecutive patients with definite LNVIE treated at a tertiary cardiothoracic centre. TTEstudies performed within the first sevendays of the index blood culture (for culture-positive cases) or hospital admission (for culture-negative cases) were reviewed for the presence of valvular vegetations, perivalvular abscesses, aortic or mitral regurgitation of moderate or greater severity or a bicuspid aortic valve. Six-week outcomes included all-cause mortality, cardiac surgery for endocarditis or new embolic cerebral infarction. Early TTE was performed in 118 of 151 episodes of definite LNVIE at a median of twodays after the index blood culture or hospital admission. Findings on these studies included valvular vegetations or abscesses in 74 patients, moderate or severe aortic or mitral regurgitation in 67 patients and a bicuspid aortic valve in 19 patients. The presence of any of these findings conferred a relative risk of any adverse six-week outcome of 4.80 (95% confidence interval 1.6-17, p = 0.001). The presence of a bicuspid aortic valve appeared particularly predictive of the need for cardiac surgery, including for clinically occult paravalvular abscesses. Early TTE can be used to stratify patients with LNVIE by the risk of major endocarditis-related adverse outcomes occurring within the first sixweeks of treatment.

Impact of Microbiological Organism Type on Surgically Managed Endocarditis

This study describes the impact of organism and valve type on surgically managed infective endocarditis (IE) from The Society of Thoracic Surgeons (STS) database. We developed a risk model for surgically managed endocarditis that includes the microbiological organism. The STS database was queried for adult patients with surgically managed endocarditis from July 1, 2011, to June 30, 2016. Outcomes were compared based on (1) causative microbiological organism, (2) valve type (native vs prosthetic), and (3) endocarditis on the right (tricuspid) vs left (mitral, aortic) sides. Univariate and risk adjusted models were developed with odds ratios for mortality for each organism type referenced against Streptococcus. The study population included 21,388 operations (93%) for left-sided IE and 1698 (7%) for right-sided IE. Streptococcus (28%) and Staphylococcus (27%) were the most common infecting organisms, followed by Enterococcus (11%). After multivariate adjustment, microbiological organism type was significantly associated with operative mortality for patients with left-sided endocarditis, with an adjusted odds ratio of 2.9 for fungal, 1.4 for Staphylococcus, and 1.3 for culture-negative vs Streptococcus. For right-sided endocarditis, there were no differences in outcomes by organism type. Left-sided prosthetic valve endocarditis had a higher operative mortality than left-sided native valve endocarditis (12% vs 8%, P < .001). In contrast, surgery for right-sided endocarditis carried lower operative mortality, with no mortality difference between prosthetic valve endocarditis and native valve endocarditis (5% vs 4%, P= .6). Organism type influences the operative mortality for left-sided endocarditis. Surgery for left-sided and prosthetic valve endocarditis is associated with higher operative mortality. Risk adjustment for operative outcomes in endocarditis may need to account for microbiological organism type.