Multidisciplinary Endocarditis Team Research Articles

Shared Decision-Making for Partial Oral Antibiotic Treatment of Infective Endocarditis: A Case Series.

Although literature has demonstrated the noninferiority of oral antibiotics in the treatment of infectious endocarditis, widespread adoption of this practice has yet to occur in the United States. We report on 32 patients with infectious endocarditis treated by a multidisciplinary endocarditis team and a standardized approach to partial oral antibiotic therapy with a high rate of clinical success.

Suppressive antibiotic therapy for infectious endocarditis

ObjectivesSuppressive antibiotic therapy (SAT) is a long-term antibiotic strategy at times applied when an indicated surgical management of infective endocarditis (IE) is not possible. Our aim was to describe the characteristics and outcomes of patients having received SAT for IE. MethodsWe conducted a retrospective, observational study at Strasbourg University Hospital, France between January 2020 and May 2023. We reviewed all medical files taken into consideration at weekly meetings of the local Multidisciplinary Endocarditis Team (MET) during the study period. We included patients having received SAT following the MET evaluation. The primary endpoint was all-cause mortality at most recent follow-up. Secondary endpoints included all-cause mortality at 3 and 6 months, infection relapse, and tolerance issues attributed to SAT. ResultsThe MET considered 251 patients during the study time, among whom 22 (9 %) had received SAT. Mean age was 77.2 ± 12.3 years. Patients were highly comorbid with a mean Charlson index score of 6.6 ± 2.5. Main indication for SAT was surgery indicated but not performed or an infected device not removed (20/22). Fourteen patients had prosthetic valve IE, including 9 TAVIs. Six patients had IE affecting cardiac implantable electronic devices. Staphylococcus aureus and enterococci were the main bacteria involved (6/22 each). Median follow-up time was 249 days (IQR 95–457 days). Mortality at most recent follow-up was 23 % (5/22). Three patients (14 %) presented tolerance issues attributed to SAT, and two patients suffered late infectious relapse. ConclusionMortality at most recent follow-up was low and tolerance issues were rare for patients under SAT, which might be a palliative approach to consider when optimal surgery or device removal is not possible.

Importance of experience in transoesophageal echocardiographic evaluation of vegetation size in patients with infective endocarditis: a reliability study

Abstract Aims Vegetation size assessed by transoesophageal echocardiography (TOE) is a decisive metric in guiding surgical intervention and prognosis in patients with definite infective endocarditis (IE). The aim of this study was to assess the impact of echocardiographic experience on the reliability and reproducibility of TOE measurements of vegetations in patients with IE. Methods and results Twenty-nine raters from a cardiac department at a tertiary centre were divided into three groups according to echocardiographic experience: experts, cardiologists, and novices. All raters were instructed to measure the maximum length of vegetations in 20 different TOE exams. Interrater agreement was evaluated using intraclass correlation coefficient (ICC), one-way analysis of variance, Kruskal–Wallis test, and Bland–Altmann plots. Reliability was assessed by minimal detectable change (MDC). All measurements were compared with the measured size agreed on by the multi-disciplinary IE team. There was an overall significant interrater variance between the three groups (P < 0.001). The variance was 10.1, 14.8, and 21.7 for the experts, cardiologists, and novices, respectively. ICC was excellent for experts (96.3%) and cardiologists (93.7%) and good for novices (84.6%). The three groups tended to measure smaller than the endocarditis team. MDC was 2.6 mm for experts, 3.3 mm for cardiologists, and 3.6 mm for novices. Conclusion The study showed good to excellent intraclass correlation but high dispersion in all groups. Variance decreased with higher experience. Our findings support current recommendations that complicated cases should be cared for by the multi-disciplinary endocarditis team and underline the importance of echocardiographic expertise when evaluating and measuring vegetations in patients with IE.

International Survey on Perioperative Management of Patients With Infective Endocarditis

To estimate the current practice in the perioperative management of patients undergoing cardiac surgery due to infective endocarditis. A prospective, open, 24-item, web-based cross-sectional survey. Online survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC). Members of the EACTAIC. None. A total of 156 responses from 44 countries were received, with a completion rate of 99%. The response rate was 16.6%. Most respondents (76%) practiced cardiac anesthesia in European hospitals, and most respondents stated that a multidisciplinary endocarditis team was not established at their center, that cardiac anesthesiologists appeared to be involved infrequently in those teams (36%), and that they were not involved in decision-making on indication and timing of surgery (88%). In contrast, the cardiac anesthesiologist performed intraoperative antibiotic therapy (62%) and intraoperative transesophageal echocardiography (90%). Furthermore, there was a relative heterogeneity concerning perioperative monitoring, as well as for coagulation and transfusion management. This international survey evaluated current practice among cardiac anesthesiologists in the perioperative management of patients with infective endocarditis and the anesthesiologist's role in multidisciplinary decision-making. Heterogeneity in treatment approaches was identified, indicating relevant knowledge gaps that should encourage further clinical research to optimize treatment and postoperative outcomes in this specific population.

1981. Alternatives to guideline directed therapy in bacterial endocarditis

Abstract Background Existing society guidelines recommend therapy with intravenous antibiotics for 4-6 weeks for most cases of endocarditis. Recent literature has demonstrated that partial oral antibiotic treatment is non-inferior to intravenous therapy and that partial treatment with dalbavancin or shorter durations of therapy in patients undergoing valve surgery can also lead to positive clinical outcomes. However, there is not currently a standardized approach to how these alternative treatments should be utilized. Methods A standardized protocol for use of shortened duration of antibiotic treatment post-operatively, oral antibiotic therapy, and dalbavancin was developed by the endocarditis consult service in conjunction with the University of Kentucky multidisciplinary endocarditis team. Subsequently, consecutive patients with endocarditis treated with these alternative therapies were identified and reviewed by study investigators. The primary outcomes were 90-day mortality, 30-day readmission, relapsed infection, and completion of therapy. Results Between September 7th, 2021 and April 15th, 2022 we identified 20 cases of endocarditis managed with one of the alternative treatment regimens. Fourteen patients had recent injection drug use. Twelve patients were initially treated with partial oral therapy. Five patients were initially treated with dalbavancin. Three patients received two-week courses of intravenous antibiotics after valve surgery. For all patients, 90-day mortality was 0% and 30-day readmission rate was 10%. Ten patients completed oral treatment. Three patients completed therapy with Dalbavancin with two patients transitioning to the oral group due to side effects. All three patients with shortened durations of therapy completed treatment. One patient treated with dalbavancin with crossover to oral therapy developed relapsed bacteremia with the same organism after self-discontinuing a suppressive oral antibiotic. Conclusion A systematic approach involving a multidisciplinary team can allow for successful utilization of alternative approaches to guideline directed treatment for endocarditis with high rates of therapy completion, low rates of mortality, re-admission, and relapsed infection, including in persons who inject drugs. Disclosures All Authors: No reported disclosures.

The impact of the multidisciplinary Endocarditis Team on the management of infective endocarditis.

In their latest guidelines for infective endocarditis (IE) (2015), the European Society of Cardiology (ESC) introduced the implementation of the Endocarditis Team (ET) to facilitate the management of IE. This study presents our experiences and the diagnostic and therapeutic impact of the ET on the management of IE. From 2016-2020, data of all patients with suspected IE referred to the ET were prospectively collected. The final diagnosis was defined by the ET as either rejected, possible or definite IE. Diagnostic impact was scored as any change in initial diagnosis, the frequency of additional diagnostic tests advised by the ET and any change in diagnosis after these tests. Therapeutic impact was scored as any change in antibiotic therapy or change from conservative to invasive therapy or vice versa. Atotal of 321patients (median age67 [55-77] years, 71% male) were enrolled. The final diagnosis was rejected IE in 47(15%), possible IE in 34(11%) and definite IE in 240 (75%) patients. Achange of initial diagnosis was seen in 53/321(17%) patients. Additional microbiological tests were advised in 69/321 (21%) patients, and additional imaging tests in 136/321 (42%) patients, which resulted in subsequent change in diagnosis in 23/321 (7%) patients. Any change in antibiotic treatment was advised in 135/321 (42%) patients, and change from initial conservative to additional surgical treatment in 15/321 (5%) patients. The ET had aclear impact on the therapeutic policy for patients with suspected IE and is useful in the management of this life-threatening disease. Broad implementation is warranted.

The impact of implementing an endocarditis team in comparison to the classic heart team in a tertiary referral centre

BackgroundInfective endocarditis (IE) is a complex disease for which the European Society of Cardiology guideline recommends a dedicated multidisciplinary endocarditis team (ET) approach since 2015. It is currently unknown whether this ET approach is beneficial compared to a classic heart team approach including bedside consultation by an infectious disease specialist in Western Europe.MethodsThis retrospective single centre, observational cohort study was conducted at the Radboudumc, a tertiary referral centre in the Netherlands. Consecutive patients treated for IE were included from September 2017 to September 2018 before implementation of a dedicated ET and from May 2019 to May 2020 afterwards.ResultsIn total, 90 IE patients (45 patients before and 45 patients after the implementation of the ET) were included. No significant differences were found in diagnostic workup, surgical treatment (surgery performed 69% vs. 71%, p = 0.82), time to surgery because of an urgent indication (median 4 vs. 6 days, p = 0.82), in-hospital complications (53% vs. 67%, p = 0.20), and 6-month mortality (11% vs. 13%, p = 0.75) between IE patients treated before and after the implementation of the ET.ConclusionFormalization of the recommended multidisciplinary endocarditis team might not significantly improve the complication rate nor the short term outcome.

Partial oral antibiotic treatment of endocarditis in patients who inject drugs: a case series

BackgroundRecent literature has demonstrated that partial oral antibiotic treatment of infectious endocarditis is non-inferior to IV therapy in select patients. Despite the rising incidence of injection drug use-related endocarditis, partial oral therapy has not been well studied in persons who inject drugs.ObjectivesTo evaluate the rate of relapsed infection and 90 day mortality in patients with infectious endocarditis treated with partial oral antibiotic therapy.MethodsConsecutive patients with infectious endocarditis treated with partial oral antibiotic therapy were identified by study investigators and reviewed by independent clinicians. The decision to use partial oral antibiotic therapy was made by the institution’s multidisciplinary endocarditis team.ResultsIn 11 cases of infective endocarditis treated with partial oral antibiotic therapy, 9 of which were complicated by injection drug use, there were no relapsed infections with the primary organism. Five patients underwent surgical valve replacement, and the median duration of oral antibiotic therapy was 23 days. All patients survived to in-hospital discharge and 90 days post-discharge. Ten patients followed up with an infectious diseases provider after discharge.ConclusionsThese data add to existing literature demonstrating non-inferior outcomes with partial oral antibiotic treatment when compared with IV antibiotic treatment alone in patients with endocarditis, including persons who inject drugs.

Multimodality imaging leads to increased diagnostic certainty for the endocarditis multidisciplinary team

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): NA Background Endocarditis is a complex condition with high rates of morbidity and mortality. The clinical presentation is highly variable and diagnosis may be difficult. ESC guidelines include modified diagnostic criteria utilising both Duke criteria and multimodality imaging techniques in order to improve sensitivity. A Multidisciplinary Endocarditis Team (MDT) is recommended to improve patient care and has been shown to reduce 1 year mortality. We have established a local endocarditis team, with remote input from our regional cardiothoracic centre. During weekly virtual multidisciplinary meetings (MDM), all patients with suspected endocarditis are discussed, with recommendations on investigations, antimicrobial therapy and management. Purpose We audited the use of multimodality imaging in the diagnosis of endocarditis before and after the implementation of the MDM to compare management strategies. Methods Inpatients who were clinically diagnosed and treated for endocarditis in the first 6 months of 2019 (pre MDT – Group 1, n = 30) and 2021 (with MDT input - Group 2, n = 21) were included. Likelihood of endocarditis was calculated using the modified Duke score and multimodality imaging, resulting in categories of definite IE, possible IE and rejected IE. Imaging specifically requested for the diagnosis of endocarditis (or infection/embolic source) was recorded. Where imaging criteria were demonstrated, the modality making this diagnosis was recorded. Results In both groups all patients had a transthoracic echocardiogram (TTE) with a similar diagnostic yield: (20%) in group 1 and 6(29%) in group 2, p = 0.481. In group 1, 13 patients without diagnostic criteria on TTE had a second investigation, with a further 4 meeting imaging criteria. 1 patient had a third test. In group 2, 13 had a second test with a further 8 meeting imaging criteria. 3 patients had a third test with 1 further positive result (Figure 1). There was increased usage of additional testing after a normal TTE in group 2 (87%) compared to group 1 (54%), p = 0.036. Overall, in group 1, 10(33%) patients demonstrated imaging criteria for endocarditis. In group 2, this increased to 15(71%), p = 0.008. A wider spread of imaging techniques was used in group 2 (Figure 1). In group 1, diagnostic criteria were found on TTE (60%) or TOE (40%). In group 2, they were seen from all four modalities: TTE (40%), TOE (33%), FDG-PET (20%) and CT (7%). In group 1, the spread of diagnostic classification was: • Definite endocarditis - 6(20%) • Possible endocarditis - 13(43%) • Rejected endocarditis - 11(37%) In group 2, this was: • Definite endocarditis - 12(57%) • Possible endocarditis - 9(43%) Conclusion Creation of endocarditis MDT resulted in increased use of multimodality imaging in patients with suspected endocarditis, resulting in a higher diagnostic yield and an increase in diagnostic certainty. Abstract Figure.

Management of infective endocarditis in pregnancy by a multidisciplinary team: a case series.

Introduction:The incidence of infective endocarditis (IE) in pregnancy is rare and has been increasing during the opioid epidemic. IE in pregnancy is associated with high rates of maternal and fetal morbidity and mortality. Multidisciplinary endocarditis teams for management of IE have been shown to reduce in-hospital and 1-year mortality. We present a single-center experience managing IE in pregnancy utilizing a multidisciplinary endocarditis team.Methods:Patients diagnosed with IE while pregnant or within 30 days post-partum were identified. All patients discussed at the institution’s weekly multidisciplinary endocarditis meeting were included. Demographic and clinical data and outcome-related variables were retrospectively reviewed and recorded.Results:Between 1 October 2020 and 1 June 2021 6 pregnant or 30-day post-partum patients with IE were identified. All patients had co-morbid injection drug use; Staphylococcus aureus was the etiologic pathogen in all patients. All patients had embolic complications and 5 required ICU admission and mechanical ventilatory support. Four patients underwent valve replacement. There were no patient-directed discharges. All patients survived to hospital discharge and 90-days after diagnosis. Four pregnancies resulted in delivery at an average gestational age of 32.4 weeks with 3 requiring NICU admissions and prolonged lengths of stay. All patients were seen by addiction medicine and 5 were started on medication-assisted treatment for opioid use disorder.Discussion:In a small retrospective cases series, coordination of care by a multidisciplinary endocarditis team led to a high-rate of surgical intervention with no patient-directed discharges and no in-hospital or 90-day mortality.Conclusion:Multidisciplinary endocarditis teams are a low-risk intervention that may improve outcomes in pregnant patients with IE.

Fungal endocarditis after type a dissection, a positive outcome from Candida parapsilosis prosthetic aortic valve endocarditis and aortic graft infection: A testament to multidisciplinary practice

• Fungal endocarditis is increasing in prevalence and remains challenging to manage both acutely and in the chronic phase. • Dual anti-fungal therapy and timely operative management are the mainstays of effective treatment. • A prolonged multidisciplinary approach is important in managing these complex patients. Fungal endocarditis is associated with a very poor prognosis (mortality in excess of 50%) and the incidence is increasing due, in part, to the increased implantation of intra-cardiac devices and valve replacements. Diagnosis and treatment remain challenging, with the need for prolonged courses of dual, parenteral anti-fungal therapy that have several drug-drug interactions and side effects that require protracted monitoring. Moreover, there is uncertainty on the optimal management strategy for fungal endocarditis as, given its rarity, much of the evidence comes from small observational studies. We report a case of Candida parapsilosis prosthetic valve endocarditis and aortic graft infection necessitating a high-risk redo aortic valve replacement. This case illustrates the important role of the multidisciplinary Endocarditis Team in achieving a good outcome, despite year-long treatment and geographical separation of patient from the regional centre and Endocarditis Team expertise.

Adherence to guidelines of diagnostic and therapeutic practices for suspected infections of cardiac implantable electronic devices

Abstract Background Despite guidelines describing the optimal diagnostic and therapeutic procedures of patients with suspected infection of cardiac implantable electronic device (CIED), the management of such patients is often challenging. Purpose The aim of this study was to describe our diagnostic and therapeutic practices for suspected CIED infection and to compare them to European Heart Rhythm Association (EHRA) guidelines. Methods Patients hospitalized in our tertiary care hospital for suspected CIED infection from 2014 to 2019 were retrospectively included. We applied the EHRA classification and compared diagnostic and therapeutic management to EHRA guidelines. Results Among 184 patients (mean age 72.3±12.4 years), 137 had a proven infection of the lead (either by TTE/TEE, by [18F]FDG PET/CT, or by positive culture of the lead) or an isolated pocket infection without proof of lead infection and 47 had no proof of infection of CIED. According to EHRA classification, CIED infection was considered as definite in 145 patients, possible in 31 and excluded in 8. Regarding recommended diagnostic procedures, blood cultures were performed in 90.8%, TTE in 97.8%, TEE in 85.9%, [18F]FDG PET/CT in 50.5% and imaging for embolisms in 78.3% of the patients. Compared to therapeutic recommendations for the 145 cases of definite CIED infection, device removal was performed in 96 patients (66.2%), antibiotic therapy was prescribed in 130 (89.7%), with a duration equal or superior to the one recommended in 105 (72.4%) of the patients. One-year survival rate was 66.3% and was better in patients with device removal than in patients without, both in the whole population (respectively 77.7% and 48.6%) and in the patients with definite CIED infection (80.0% vs 49.0%). After adjustement on age and Charlson's score, patients without device removal had a significantly higher risk of 1-year mortality (HR=3.40 [1.84–6.26], p=0.0001). Conclusion Suspicion of CIED infection are difficult situations. The use of theoretical classification helps to define the different types of cases and the resultant therapeutic approach. In daily practice, our study shows that the strict adherence to these guidelines is not always possible. This study shows a relatively good use of diagnostic procedures. However, theoretical advice for medical therapy and removal procedures are not always properly followed. To improve patients' prognosis, infected device removal must be systematically discussed in multidisciplinary endocarditis team, weighing the benefit-risk ratio of the strict appliance of the guidelines. Funding Acknowledgement Type of funding sources: None. Diagnostic comparisonTherapeutic comparison

Long-term antibiotic therapy in patients with surgery-indicated not undergoing surgery infective endocarditis.

To date, there is little information regarding management of patients with infective endocarditis (IE) that did not undergo an indicated surgery. Therefore, we aimed to evaluate prognosis of these patients treated with a long-term antibiotic treatment strategy, including oral long term suppressive antibiotic treatment in five referral centres with a multidisciplinary endocarditis team. This retrospective, multicenter study retrieved individual patient-level data from five referral centres in Spain. Among a total of 1797, 32 consecutive patients with IE were examined (median age 72 years; 78% males) who had not undergone an indicated surgery, but received long-term antibiotic treatment (LTAT) and were followed by a multidisciplinary endocarditis team, between 2011 and 2019. Primary outcomes were infection relapse and mortality during follow-up. Among 32 patients, 21 had IE associated with prostheses. Of the latter, 8 had an ascending aorta prosthetic graft. In 24 patients, a switch to long-term oral suppressive antibiotic treatment (LOSAT) was considered. The median duration of LOSAT was 277 days. Four patients experienced a relapse during follow-up. One patient died within 60 days, and 12 patients died between 60 days and 3 years. However, only 4 deaths were related to IE. The present study results suggest that a LTAT strategy, including LOSAT, might be considered for patients with IE that cannot undergo an indicated surgery. After hospitalization, they should be followed by a multidisciplinary endocarditis team.

The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team

BackgroundInfectious endocarditis is associated with substantial in-hospital mortality of 15%-20%. Effective management requires coordination between multiple medical and surgical subspecialties, which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality. MethodsThe multidisciplinary endocarditis team was formed in May 2018. The group developed an evidence-based algorithm for management of endocarditis that was used to provide recommendations for hospitalized patients over a 1-year period. Mortality outcomes were then retroactively assessed and compared to a historical control utilizing propensity matching. ResultsBetween June 2018 and June 2019 the team provided guideline-based recommendations on 56 patients with Duke Criteria–definite endocarditis and at least 1 American Heart Association indication for surgery. The historical control included 68 patients with definite endocarditis and surgical indications admitted between July 1, 2014, and June 30, 2015. In-hospital mortality decreased significantly from 29.4% in 2014-2015 to 7.1% in 2018-2019 (P < .0001). There was a non-significant increase in the rate of surgical intervention after implementation of the team (41.2% vs 55.4%; P = 0.12). Propensity score matching demonstrated similar results. ConclusionsImplementation of a multidisciplinary endocarditis team was associated with a significant 1-year decrease in all-cause in-hospital mortality for patients with definite endocarditis and surgical indications, in the presence of notable differences between the 2 studied cohorts. In conjunction with previous studies demonstrating their effectiveness, these data support the idea that widespread adoption of endocarditis teams in North America could improve outcomes for this patient population.

A step-by-step guide to implementing a multidisciplinary endocarditis team.

Over the last several years multiple studies, primarily from European centers have demonstrated the clinical and outcomes benefits of multidisciplinary endocarditis teams. Despite this literature, adoption of this approach to patient care has been slower in the United States. While there is literature outlining the optimal composition of an endocarditis team, there is little information to guide providers as they attempt to transform practice from a fragmented, disjointed process to an efficient, collaborative care model. In this review, the authors will outline the steps they took to create and implement a successful multidisciplinary endocarditis team at the University of Michigan. In conjunction with existing data, this piece can be used as a resource for clinicians seeking to improve the care of patients with endocarditis at their institutions.

713. The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team

BackgroundInfectious endocarditis is associated with substantial in-patient mortality of 15-20%. Effective management requires coordination between multiple medical and surgical subspecialties which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality.MethodsThe University of Michigan Multidisciplinary Endocarditis Team was formed on May 3rd, 2018. The group developed an evidence-based algorithm for management of endocarditis that was used to provide recommendations for hospitalized patients over a 1-year period. Mortality outcomes were then retroactively assessed and compared to a historical control that was identified using an internal research tool.Figure 1 Table 1 ResultsBetween June 14th, 2018 and June 13th, 2019 the team provided guideline-based recommendations on 56 patients with Duke Criteria definite endocarditis and at least 1 American Heart Association indication for surgery. The historical control included 68 patients with definite endocarditis and surgical indications admitted between July 1st, 2014 to June 30th, 2015. In-hospital mortality decreased significantly from 29.4% in 2014-2015 to 7.1% in 2018-2019 (p< 0.0001). There was a non-significant increase in the rate of surgical intervention after implementation of the team (41.2% vs 55.4%; p=0.12).Table 2 Table 3 Table 4 ConclusionImplementation of a multidisciplinary endocarditis team was associated with a significant 1-year decrease in all-cause in-hospital mortality for patients with definite endocarditis and surgical indications. In conjunction with previous studies demonstrating their effectiveness, this data supports that widespread adoption of endocarditis teams in North America has the potential to improve outcomes for this patient population.Table 5 Disclosures All Authors: No reported disclosures

Discrepancies between the decisions of an endocarditis team and the modified Duke's Criteria for the diagnosis of infective endocarditis

Abstract Background/Introduction The 2015 ESC endocarditis guidelines recommend that a multi-disciplinary endocarditis team should be involved in caring for patients with endocarditis. This approach recognises the heterogeneity of infective endocarditis, and the difficulty in distinguishing endocarditis from other infective and non-infective diseases. Purpose This study looks at suspected cases of infective endocarditis discussed at the endocarditis MDT, discrepancies between MDT outcome and the modified Duke's criteria in diagnosing endocarditis, and number of referrals to MDT over time. Methods Patients were identified by review of MDT outcome forms. Demographic data, predisposing conditions, imaging findings, microbiology results and final diagnosis were identified by reviewing MDT forms and electronic charts. Results 234 patients were identified from MDT outcome forms. 118 (50.4%) patients were over 65, 165 (70.5%) were male, and 65 (27.8%) had previous valve surgery. Crosstabulation of MDT decision against outcome by modified Duke's criteria are seen in Table 1. The endocarditis team identified 7 patients with definite or possible endocarditis who were excluded by applying the modified Duke's criteria. 1 of these patients required aortic valve replacement. 2 patients with disseminated Staphylococcal infections without endocarditis were classed as definite endocarditis by the modified Duke's criteria. Referral data and outcomes are included in Figure 1. Conclusions The endocarditis team can be used to improve the sensitivity and specificity of the modified Duke's criteria. As the endocarditis team became established the volume of referrals has increased, along with the number of patients who have alternate diagnoses. Practitioners should bear this in mind when establishing endocarditis teams. Figure 1. Referrals over time by outcome Funding Acknowledgement Type of funding source: None

ST segment elevation caused by ostial right coronary artery obstruction in infective endocarditis: a case report

BackgroundAcute coronary syndrome (ACS) is a rare, but serious complication of infective endocarditis, and diagnosis can be challenging given clinical overlap with other syndromes. A rare cause of ACS in infective endocarditis is mechanical obstruction of the coronary artery. We present the case of a patient with infective endocarditis who developed ST segment myocardial infarction due to occlusion of the right coronary artery ostium by a vegetation.Case presentationA 53-year-old female with no prior history of coronary artery disease was transferred to our tertiary care facility for evaluation and treatment of suspected myopericarditis. After transfer she developed inferior ST segment elevations on ECG along with fever and positive blood cultures for methicillin susceptible Staphylococcus aureus (MSSA). A transesophageal echocardiogram revealed a vegetation on the aortic valve that intermittently prolapsed into the right coronary ostium. She decompensated from a hemorrhagic brain infarct and subsequently transferred to the intensive care unit. She underwent surgical aortic valve debridement without prior cardiac catheterization given the danger of septic coronary embolization. After a prolonged hospital course with multiple complications, she was able to discharge home, with no neurologic deficits on follow-up.ConclusionsACS presents a diagnostic and therapeutic challenge in the setting of infective endocarditis. Careful attention to the history, physical exam and testing can help differentiate infective endocarditis from other conditions sharing similar symptoms. Traditional atherosclerotic ACS management may cause great harm when treating patients with infective endocarditis. The presence of a multidisciplinary endocarditis team is ideal to provide the best clinical outcomes for this population.

A Multidisciplinary Pathway for the Diagnosis and Treatment of Infectious Endocarditis.

Clinical pathways can be useful when disparate clinical-pathologic groups converge on a common diagnostic and therapeutic trajectory. The progressive increase in the incidence of endocarditis in the US has included higher-risk subjects whose candidacy for aggressive cardiac surgical intervention may be highly resource-intensive, prohibitively high risk, or delayed and possibly deferred by comorbidities. We sought to define the sequence, application, and resolution of multidisciplinary endocarditis team decision-making in 4 distinct clinical groups.

Physician perceptions of a multidisciplinary endocarditis team.

Infectious endocarditis is a highly morbid infection that requires coordination of care across medical and surgical specialties, often through the use of a multidisciplinary team model. Multiple studies have demonstrated that such conferences can improve clinical outcomes. However, little is known about physicians' impressions of these groups. We surveyed 126 (response rate of 30%) internal medicine, infectious diseases, cardiology, and cardiac surgery providers 1year after the implementation of an endocarditis team at the University of Michigan. Ninety-eight percent of physicians felt that the endocarditis team improved communication between specialties. Additionally, over 85% of respondents agreed that the group influenced diagnostic evaluation, reduced management errors, increased access to surgery, and decreased in-hospital mortality for endocarditis patients. These results suggest that multidisciplinary endocarditis teams are valued by physicians as a tool to improve patient care and serve an important role in increasing communication between providers.