Native Infective Endocarditis Research Articles

An alternative surgical approach for isolated pulmonary valve infective endocarditis secondary to restrictive ventricular septal defect: a case report

BackgroundNative pulmonary valve (PV) infective endocarditis (IE) is a rare condition with an incidence of 1.5–2%. Although medical therapy is the mainstay of treatment, surgical intervention is still indicated in cases that fail to respond to antibiotics. To date, there is lack of consensus about the best surgical approach for isolated native PV IE. While valve repair is sometimes feasible, most of the cases require valve replacement depending on the extent of tissue damage. A stented bioprosthesis can be used when infection is confined to the valve leaflets. However, extension of damage to the pulmonary root or right ventricular outflow tract usually requires debridement and root replacement.Case presentationA 30-year-old lady with a long history of restrictive ventricular septal defect (VSD) presented with fever and shortness of breath shortly after vaginal delivery that was diagnosed as isolated PV IE with pulmonary septic emboli. After 1 week of antibiotic therapy, there was no response with persistent infection and complete valve destruction. Heart team discussion recommended PV replacement using a Freestyle valve along with VSD repair. On follow-up after 1 year, she was doing fine with well-functioning Freestyle valve.ConclusionUnrepaired restrictive VSD can be a predisposing factor for native PV IE. A Freestyle valve in the pulmonary position is a valid option for such cases, with good early outcomes and reasonable durability, particularly when there is extensive tissue infection and homograft is not available. More evidence is still required to evaluate the long-term outcomes of PV Freestyle in cases of IE.

Do we need to improve the general oral health of our population to reduce the risk of Infective Endocarditis?

Abstract Background Emphasis is placed on the link between oral health and Infective Endocarditis (IE), particularly around odontogenic infections and specific dental procedures. The Adult Dental Health Survey in 2009 showed 45% of adults in the UK required dental intervention typically associated with developing IE. Antibiotic prophylaxis in this context is not without controversy. With gum and periodontic disease endemic, is the modern issue one of generalised poor oral health as a risk factor for IE? Purpose To determine the impact of oral health on risk and outcome in IE. Terminology SDCEP published dental guidelines of when to consider AP against IE for dental procedures. It identifies dental procedures that can cause transient bacteraemia. Methodology Data were collected from October 2020-Januaury 2023 in 123 patients with confirmed IE at a central London cardiac surgical centre. Patients had a focussed dental assessment with history, intraoral examination and dental panoramic radiograph to determine the risk and extent of oral disease. Results Average age was 54.2years. 77/123 (63%) had native IE (NVE) and 46 (37%) prosthetic (PVE). 17 (37%) cultured oral organisms from blood (Table 1); 8 (47%) of these organisms are associated with active dental disease (decay, periodontal disease, dental infection). Organisms can be found in Table 2. However, 93/123 (76%) had oral caries requiring dental treatment, irrespective of typical portal of entry for that organism. The proposed dental treatment posed a high risk for causing IE in 70%. 93/123 (76%) needed further dental treatment within six months rendering only 12% of patients orally stable. Oral organisms were seen more frequently in NVE (41/77) vs PVE (17/46). There was no difference in the incidence of dental disease requiring treatment (77% NVE vs 74% PVE). Whilst 27% of PVE had had recent (within 4 months) dental treatment compared to 73% NVE, only 1 PVE patient grew an oral commensal compared to 82% of NVE patients. Conclusion Prevention of IE is key to reducing the morbidity and mortality of this disease. We see oral commensals causing IE in 47%, with only 12% of this modern IE cohort dentally stable. Despite this, there was no difference in rates of dental disease requiring invasive treatment when stratified by oral vs non-oral organisms. A robust public health strategy is required to reduce the risk of oral disease driving IE.

Mid-term outcomes following the Hemi-Commando procedure for complex infective endocarditis involving the aortomitral junction.

Perivalvular abscesses with destruction of the aortomitral junction (AMJ) are a severe complication of infective endocarditis (IE) and are associated with high mortality and complex management. The Hemi-Commando procedure is a mitral valve-sparing alternative to the Commando procedure in suitable patients with complex IE and paravalvular destruction. This study reviews the mid-term outcomes in patients undergoing the Hemi-Commando procedure for treating IE with destruction of the AMJ. The clinical outcomes of patients with IE and AMJ involvement who underwent the Hemi-Commando procedure between 2015 and 2021 at the Leipzig Heart Center were retrospectively analysed. Primary outcomes were 30-day mortality and 1-year survival. Secondary outcome was 1-year freedom from reoperation. A total of 22 patients underwent the Hemi-Commando procedure during the study period. The patients' mean age was 59.8 ± 18.3 years. The study population was predominantly male (86.4%). Preoperative sepsis was present in 6 (27.3%) patients, and the median EuroSCORE II was 28.5%. Almost two-thirds (N = 14; 63.6%) of the patients presented with native IE. Streptococci were the most common pathogens (N = 8; 36.4%). Paravalvular abscess was found intraoperatively in 16 (72.7%) patients. The 30-day mortality was 13.6%. The estimated 1- and 3-year survival rates were 77.5% and 66.4%, respectively. The estimated freedom from reoperation at 1 and 3 years was 92.3%. The Hemi-Commando procedure offers an acceptable mid-term survival chance with low reoperation rates and is, therefore, a reasonable mitral valve-sparing alternative to the Commando procedure in suitable patients with extensive IE and perivalvular involvement.

Characteristics, management, and outcomes of patients with left-sided infective endocarditis complicated by heart failure: a substudy of the ESC-EORP EURO-ENDO (European infective endocarditis) regist

Abstract Background/Introduction Congestive heart failure (CHF) is a strong prognostic factor in infective endocarditis (IE), but data are lacking regarding its current management and outcome in Europe. Purpose To evaluate the current management and survival of patients with left-sided IE complicated by CHF. Methods We used data of the ESC-EORP EURO-ENDO registry, which is a prospective multicentre observational study conducted between January 1, 2016 and March 31, 2018 in 156 centres in 40 countries. The primary endpoints were 30-day and one-year mortality. Results Among the 3116 patients enrolled in this prospective registry, 2449 (mean age: 60 years, 69% male) with left-sided (native or prosthetic) IE were included in this study. Patients with CHF (n=698, 28.5%) were older, with more comorbidity and more severe valvular damage (mitro-aortic involvement, vegetations >10mm and severe regurgitation/new prosthesis dehiscence) than those without CHF (all p≤0.019). Patients with CHF experienced higher 30-day and one-year mortality than those without (20.5% vs. 9.0% and 36.1% vs. 19.3%, respectively) and CHF remained strongly associated with 30-day (OR [95% CI]: 2.37 [1.73–3.24]; p<0.001) and one-year mortality (HR [95% CI]: 1.69 [1.40–2.05]; p<0.001) after adjustment for established outcome predictors, including early surgery, or after propensity matching for age, sex, and comorbidity (n=618 [88.5%] for each group, both p<0.001). Early surgery, performed on 49% of these patients with IE complicated by CHF, remained associated with a substantial reduction in 30-day mortality following multivariable analysis, after adjustment for age, sex, Charlson index, cerebrovascular accident, staphylococcus aureus IE, Streptococcal IE, uncontrolled infection, vegetation size >10mm, severe valvular regurgitation and/or new prosthetic dehiscence, perivalvular complication, and prosthetic IE (OR [95% CI]: 0.22 [0.12–0.38]; p<0.001) and in one-year mortality (HR [95% CI]: 0.29 [0.20–0.41]; p<0.001). Conclusion CHF is common in left-sided IE and is associated with older age, greater comorbidity, more advanced lesions, and markedly higher 30-day and one-year mortality. Early surgery is strongly associated with lower mortality but is performed on only approximately half of patients with CHF, mainly because of a surgical risk considered prohibitive. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott Vascular Int. (2011–2014) Amgen Cardiovascular (2009–2018),

Infective endocarditis in pregnant women without intravenous drug use: a multicentre retrospective case series.

To describe the clinical features and outcomes of infective endocarditis (IE) in pregnant women who do not inject drugs. A multinational retrospective study was performed at 14 hospitals. All definite IE episodes between January 2000 and April 2021 were included. The main outcomes were maternal mortality and pregnancy-related complications. Twenty-five episodes of IE were included. Median age at IE diagnosis was 33.2 years (IQR 28.3-36.6) and median gestational age was 30 weeks (IQR 16-32). Thirteen (52%) patients had no previously known heart disease. Sixteen (64%) were native IE, 7 (28%) prosthetic and 2 (8%) cardiac implantable electronic device IE. The most common aetiologies were streptococci (n = 10, 40%), staphylococci (n = 5, 20%), HACEK group (n = 3, 12%) and Enterococcus faecalis (n = 3, 12%). Twenty (80%) patients presented at least one IE complication; the most common were heart failure (n = 13, 52%) and symptomatic embolism other than stroke (n = 4, 16%). Twenty-one (84%) patients had surgery indication and surgery was performed when indicated in 19 (90%). There was one maternal death and 16 (64%) patients presented pregnancy-related complications (11 patients ≥1 complication): 3 pregnancy losses, 9 urgent Caesarean sections, 2 emergency Caesarean sections, 1 fetal death, and 11 preterm births. Two patients presented a relapse during a median follow-up of 3.1 years (IQR 0.6-7.4). Strict medical surveillance of pregnant women with IE is required and must involve a multidisciplinary team including obstetricians and neonatologists. Furthermore, the potential risk of IE during pregnancy should never be underestimated in women with previously known underlying heart disease.

Characteristics, management, and outcomes of patients with left-sided infective endocarditis complicated by heart failure: a substudy of the ESC-EORP EURO-ENDO (European infective endocarditis) registry.

AimsTo evaluate the current management and survival of patients with left‐sided infective endocarditis (IE) complicated by congestive heart failure (CHF) in the ESC‐EORP European Endocarditis (EURO‐ENDO) registry.Methods and resultsAmong the 3116 patients enrolled in this prospective registry, 2449 (mean age: 60 years, 69% male) with left‐sided (native or prosthetic) IE were included in this study. Patients with CHF (n = 698, 28.5%) were older, with more comorbidity and more severe valvular damage (mitro‐aortic involvement, vegetations >10 mm and severe regurgitation/new prosthesis dehiscence) than those without CHF (all p ≤ 0.019). Patients with CHF experienced higher 30‐day and 1‐year mortality than those without (20.5% vs. 9.0% and 36.1% vs. 19.3%, respectively) and CHF remained strongly associated with 30‐day (odds ratio[OR] 2.37, 95% confidence interval [CI] [1.73–3.24; p < 0.001) and 1‐year mortality (hazard ratio [HR] 1.69, 95% CI 1.39–2.05; p < 0.001) after adjustment for established outcome predictors, including early surgery, or after propensity matching for age, sex, and comorbidity (n = 618 [88.5%] for each group, both p < 0.001). Early surgery, performed on 49% of these patients with IE complicated by CHF, remained associated with a substantial reduction in 30‐day mortality following multivariable analysis, after adjustment for age, sex, Charlson comorbidity index, cerebrovascular accident, Staphylococcus aureus IE, streptococcal IE, uncontrolled infection, vegetation size >10 mm, severe valvular regurgitation and/or new prosthetic dehiscence, perivalvular complication, and prosthetic IE (OR 0.22, 95% CI 0.12–0.38; p < 0.001) and in 1‐year mortality (HR 0.29, 95% CI 0.20–0.41; p < 0.001).ConclusionCongestive heart failure is common in left‐sided IE and is associated with older age, greater comorbidity, more advanced lesions, and markedly higher 30‐day and 1‐year mortality. Early surgery is strongly associated with lower mortality but is performed on only approximately half of patients with CHF, mainly because of a surgical risk considered prohibitive.

PO-648-08 CONCOMITANT CARDIAC VALVULAR VEGETATION IN PATIENTS WITH CARDIAC IMPLANTABLE ELECTRONIC DEVICE INFECTION IS ASSOCIATED WITH HIGHER ONE YEAR MORTALITY

The emerging data suggest that the incidence of Cardiac Implantable Electronic Devices (CIEDs) infections is on the rise. Infected CIEDs are frequently associated with native or prosthetic valvular infective endocarditis. The effect of concomitant valvular vegetation in the presence of infected CIED is not well characterized.

Co-inciding Native Infective Endocarditis and COVID-19 in an Older Patient: A Case Report

Coronavirus Disease 2019 (COVID-19) is an ongoing pandemic caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Patients with infective endocarditis (IE) and COVID-19 can present similar signs and symptoms; thus, it may be difficult for clinicians to diagnose such infections.&#x0D; This report presented a patient diagnosed with IE and co-infected with COVID-19. This case highlights that every physician should consider COVID-19 infection when evaluating patients with IE.

Comparing Echocardiographic Modalities in Native-Valve Infective Endocarditis Due to Methicillin-Resistant Staphylococcus Aureus in People Who Inject Drugs.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients.Methods: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed.Results: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE.Conclusion: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke’s criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.

WHEN LESS IS MORE: UTILIZATION OF A MULTIDISCIPLINARY APROACH IN THE TREATMENT OF NATIVE TRIPLE-VALVE INFECTIVE ENDOCARDITIS

TOPIC: Palliative Care and End of Life Issues TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis (IE) is an insidious disease with significant hospital mortality rates. While many advances have been made to manage this disease, mortality rates still remain high. These rates worsen with the involvement of multiple valves. We report a case of native triple-valve IE were an appropriate interdisciplinary approach allowed the patient to focus on maximizing his desired outcomes. CASE PRESENTATION: An 85-year-old male with a past medical history of hypothyroidism presented with symptoms of generalized malaise, progressive dyspnea, intermittent blurred vision and left sided axillary pain for five months. Initial vitals showed tachycardia and patient was notably hypoxic. Blood cultures obtained on admission showed Streptococcus gallolyticus (bovis). Transthoracic echocardiography (TTE) revealed several vegetations involving the mitral, tricuspid and aortic valves (Figure 1-3). 4 months prior to admission, the patient had presented to the outpatient clinic with a syncopal episode. Work up at the time included a TTE which revealed a normal ejection fraction and no cardiac pathology. Given the development of new onset heart failure with cardiogenic shock in the setting of multi-valve infective endocarditis, a multidisciplinary team approach was taken. Cardiology, cardiothoracic surgery and palliative medicine work together to address the patient and his families goals. After informed discussion the patient decided against pursuing invasive cardiac surgery, and opted for palliative medical management. He was eventually transitioned to at home hospice. DISCUSSION: Triple valve endocarditis while extremely rare, it is associated with high rates of morbidity and mortality. According to existing literature (1,2), multi-valve IE has been recognized as an independent survival risk factor increasing mortality rate by 3% and a four fold higher rate of in-hospital mortality. The rate of complications such as congestive heart failure and acute renal failure are also higher with involvement of multiple valves, often warranting surgical intervention (3). In these situations the recovery is often prolonged with significant morbidity to the patients. In these situations it is best to approach clinical decision making with the patients goals of care in mind. Often in medicine we jump to aggressive treatments without fully taking the patients long-term goals in mind. Our treatments need to be evaluated to see if their outcomes and associated morbidities align with patients goals. With conversation based on these principles we can provide the patient with the highest level of benevolence, and ensure they receive the outcomes they truly wish. CONCLUSIONS: Triple valve surgery is extremely challenging and confers a poor prognosis. It is necessary to weight the risks and benefits of every intervention we take and make sure they align with the patients values and goals. REFERENCE #1: Sheikh, Azeem S, et al. "Triple-Valve Infective Endocarditis." British Journal of Cardiology, Apr. 2016, pp. 23–65., doi:10.5837/bjc.2016.015 REFERENCE #2: Kim N, Lazar JM, Cunha BA, Liao W, Minnaganti V. Multi-valvular endocarditis. Clin Microbiol Infect 2000;6:207–12. https://doi.org/10.1046/j.1469-0691.2000.00065.x REFERENCE #3: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:2440-92. 10.1161/CIR.0000000000000029 DISCLOSURES: No relevant relationships by Anand Buch, source=Web Response No relevant relationships by Tapan Buch, source=Web Response No relevant relationships by Ajinkya Buradkar, source=Web Response No relevant relationships by Pooja Kharbanda, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Humza Quadir, source=Web Response No relevant relationships by Ryan Quirk, source=Web Response No relevant relationships by Mohammed Ul Haq, source=Web Response

Should We Quantify Valvular Calcifications on Cardiac CT in Patients with Infective Endocarditis?

Background: Evaluate the impact of valvular calcifications measured on cardiac computed tomography (CCT) in patients with infective endocarditis (IE). Methods: Seventy patients with native IE (36 aortic IE, 31 mitral IE, 3 bivalvular IE) were included and explored with CCT between January 2016 and April 2018. Mitral and aortic valvular calcium score (VCS) were measured on unenhanced calcium scoring images, and correlated with clinical, surgical data, and 1-year death rate. Results: VCS of patients with mitral IE and no peripheral embolism was higher than those with peripheral embolism (868 (25–1725) vs. 6 (0–95), p < 0.05). Patients with high calcified mitral IE (mitral VCS > 100; n = 15) had a lower rate of surgery (40.0% vs.78.9%; p = 0.03) and a higher 1-year-death risk (53.3% vs. 10.5%, p = 0.04; OR = 8.5 (2.75–16.40) than patients with low mitral VCS (n = 19). Patients with aortic IE and high aortic calcifications (aortic VCS > 100; n = 18) present more frequently atypical bacteria on blood cultures (33.3% vs. 4.8%; p = 0.03) than patients with low aortic VCS (n = 21). Conclusion: The amount of valvular calcifications on CT was associated with embolism risk, rate of surgery and 1-year risk of death in patients with mitral IE, and germ’s type in aortic IE raising the question of their systematic quantification in native IE.

Approach to Mitral Valve Repair in Infective Endocarditis: Single Center, Single Surgeon, Cross Sectional Study

Objective: The traditional approach was to replace the mitral valve on infective endocarditis when the response to antibiotic therapy is poor. The decision to repair the mitral valve (MV) in this setting is more challenging. This study analysed the different approaches adopted to perform a successful repair. Methods: This retrospective cross sectional study composed of all the patients referred to a single surgeon at Kandy National Hospital, Sri Lanka over a period from June 2011 to August 2020. Repair of MV in every case was the primary approach. Different types of lesion found on direct visual assessment, techniques adopted and outcome of MV repair in native MV infective endocarditis were analysed. Results: Total number of cases was 23, (16 males, 7 females) with a mean age of 42 years. MV repair was successful in all (95%) except one case, as per the intra-operative assessment made (saline test and trans esophageal echocardiography). Vegetation or leaflet perforation were the most common lesions (Posterior mitral valve leaflet/PMVL: 18, Anterior leaflet/AMVL: 7) followed by chordal rupture (6). The table shows the repair strategies used. One death occurred on postoperative third day following MV repair due to rupture of cerebral mycotic aneurysm. 22 patients were discharged home with satisfactory pre-discharge transthoracic 2D echocardiography. Conclusions: The study shows successful repair of MV on infective endocarditis is possible in majority of cases with skilled modulation of surgical approach to individual patient pathology found at the time of surgery. Long term follow-up data requires for the assessment of durability of this approach. Procedure Number Annuloplasty ring (flexible, rigid) 22 Pericardial patchAMVLPMVL 12 Folding plasty 2 Neochords 5 Triangular resection and repairAMVLPMVL 12 Quadrangular resection and repairAMVLPMVL 50 Resection and slidingplastyAMVLPMVL 26

Outpatient parenteral antimicrobial therapy (OPAT) service is associated with inpatient-bed cost savings

In a cardiology department, there are some patients that require long-term antibiotics, such as those with infective endocarditis or infected prosthetic devices. We describe our experience with intravenous antibiotic therapy for patients with cardiology diagnoses who require a period of antibiotics in our outpatient service during the period of the COVID-19 pandemic. A total of 15 patients were selected to have outpatient antibiotic therapy (age range 36 to 97 years, 60% male). A total of nine patients had infective endocarditis, four patients had infected valve prosthesis or transcatheter aortic valve implantation (TAVI) endocarditis, one patient had infected pericardial effusion while another had infected pericarditis. For these 15 patients there was a total of 333 hospital bed-days, on average 22 days per patient. These patients also had a total of 312 days of outpatient antibiotic therapy, which was an average of 21 days per patient. The total cost, if patients were admitted for those days, assuming a night cost £400, was £124,800, which was on average £8,320 per patient. Three patients were readmitted within 30 days. One had ongoing endocarditis that was managed medically and another had pulmonary embolism. The last patient had a side effect related to daptomycin use. In conclusion, outpatient antibiotic therapy in selected patients with native or prosthetic infective endocarditis appears to be safe for a selected group of patients with associated cost savings.

Feasibility and outcome of mitral valve repair in patients with infective endocarditis

BackgroundValve repair is the treatment of choice for native mitral valve regurgitation. The feasibility of repair when the defect is caused by acute infective endocarditis (IE) is debated. This study aims to compare the outcome of repair and replacement procedures, to report the rate of repair in a single surgical center, and to review the literature on this topic.ResultsWe retrospectively analyzed 108 patients with native mitral IE, potentially eligible for surgical repair. Of these 108, 90 (83%) underwent surgery, and 18 were treated conservatively. Among the 90 surgical patients, 57 (63%) underwent valve replacement and 33 valve repair (37%). The mean follow-up duration was 3 years. The two primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the post-operative incidence of major adverse events (hospitalization for any cause, pacemaker implantation, new onset of atrial fibrillation, sternal dehiscence), left ventricular systolic function (LVSF), and valvular function at 1-year echocardiographic follow-up. All-cause mortality was lower for valve repair, although not significantly (p = 0.86), as well as nonfatal adverse events (p = 0.92) and relapse rate (p = 0.20) at 3 years. We did not find differences between the two groups at echocardiographic follow-up, neither for left ventricular systolic function (p = 0.22), nor for valvular continence (p = 0.28).ConclusionsIn our experience, the mid-term outcome of repair in IE is comparable to valve replacement and should be considered whenever possible, as in degenerative valve disease. The review of the literature supports this strategy.

Timing of surgery in heart valve infective endocarditis

The prevalence of valvular infective endocarditis (IE) is increasing and is burdened by high mortality and morbidity. Despite the higher risk, the surgical approach is superior to medical therapy alone, and over the years there has been a more aggressive attitude, with earlier indications for surgery. This article aims to review the available literature and the American and European guidelines in order to summarize the most appropriate surgical timing for valvular IE. Although there are discrepancies between the guidelines, an emergent indication (<48 h) should be considered in patients with either native or prosthetic endocarditis with severe regurgitation, outflow obstruction, refractory acute pulmonary edema, cardiogenic shock, or large mobile vegetations (>15-20 mm). Patients with signs of heart failure, persistence of positive cultures for more than 48-72 h despite antibiotic therapy, and in the presence of paravalvular lesions, advanced atrioventricular block and vegetations >10 mm should be operated early (within a few days). If any micro-organisms are isolated, including fungi or multi-resistant organisms in native IE or staphylococci or gram-negative pathogens in prosthesis IE, a more watchful approach (within 2 weeks) should be evaluated. In the presence of large cerebral embolic strokes or cerebral hemorrhage, re-evaluation at 2 and 4 weeks, respectively, is more appropriate. A multidisciplinary approach, especially in the most complex cases, seems to improve the outcome.Key words. Heart valve dysfunction; Heart valve repair; Heart valve replacement; Heart valve surgery; Infective endocarditis; Timing of surgery.

Valve repair in patients with infective endocarditis

Abstract Background Valve repair is considered the treatment of choice for native mitral and tricuspid valve regurgitation but the rate of feasibility when the defect is caused by acute infective endocarditis (IE) is debated. We report the experience of valve repair versus replacement following IE in a high-volume surgical center. Methods We retrospectively analyzed 351 consecutive patients (123 women) admitted to our department with definite diagnosis of IE. IE occurred on native valves in 219 patients (62%) and on prosthetic valves in 132 (38%). Among native valves, IE involved the aortic valve in 105 cases (48%), mitral valve in 97 cases (44%) and tricuspid valve in 17 (8%). Since only native mitral and tricuspid valves are elegible for surgical repair, we limited the analysis to this subset (114 patients); of them, 92 (80.7%) underwent surgery (the final cohort) and 22 were treated conservatively, 13 due to absence of surgical indication and 9 due to prohibitive surgical risk. Long-term follow-up was obtained by structured telephone interviews. Primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the postoperative incidence of major adverse events (hospitalization for any cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence). Results Mean age at surgery was 61.9 years (SD 14.5). Mean vegetation length was 11.6 mm (SD 8.8). Endocarditis was left-sided in 80 (87%). Among the 92 surgical patients, 58 (63%) underwent valve replacement and 34 valve repair (37%). Mortality was similar between valve repair and replacement (15 vs 12%). Adverse events rate (19% vs 16%) and relapse were not statistically different between repair and replacement procedures. Conclusions The present study shows that a sizeable subgroup of consecutive patients with native mitral or tricuspid IE are amenable to valve repair in expert hands. Outcome of repair in IE is comparable to valve replacement mid-term, and should be considered whenever possible, as in degenerative valve disease. Funding Acknowledgement Type of funding source: None

A RARE CASE OF NATIVE TRIPLE-VALVE INFECTIVE ENDOCARDITIS

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Infective endocarditis (IE) is a life-threatening infection. Despite medical advances, mortality from IE remains high. Enterococcal IE is becoming more prevalent in elderly patients with degenerative valvular disease and bloodstream infections from gastrointestinal (GI) or genitourinary (GU) tracts. We present a rare case of native triple-valve infective endocarditis. CASE PRESENTATION: A 58-year-old man with a history of squamous cell carcinoma of tongue post hemiglossectomy with chemoradiation therapy and small bowel obstruction post open laparotomy a month earlier presented for altered mental status. Initial vitals showed tachycardia and was otherwise normal. Positive examination findings were cachexia, a healed partial tongue resection, decreased air entry over lung bases and left upper abdominal tenderness without peritonitis. The rest of the physical exam was unremarkable. Initial lab results were significant for leukocytosis, mild anemia, elevated BUN and creatinine. Computed tomography (CT) of chest and abdomen showed a large left lower lobe consolidation, right lower lobe patchy parenchymal disease and gastric wall thickening. He was started empirically on Zosyn, vancomycin and fluconazole. Blood cultures grew Enterococcus faecalis and transthoracic echocardiogram (echo) showed an acute-on-subacute endocarditis with vegetations on the tricuspid, mitral and aortic valves with ejection fraction 65-70%. Bronchoscopy with bronchoalveolar lavage (BAL) culture was positive for Candida Glabrata 3 days after his death. He later developed septic shock with multiorgan failure and was considered ineligible for surgery. Despite optimal medical therapy and no worsening of echo findings, he ultimately died. DISCUSSION: Multivalvular IE increases the likelihood of complications from congestive heart failure, acute renal failure, embolic events, disseminated intravascular anticoagulation and death (1). Enterococcus faecalis is an opportunistic pathogen in oral cavity, the GI and GU tracts. Manipulation of the GI and GU tracts, cancer and previous treatment with antibiotics increase the risk of enterococcal bacteremia. Our patient’s overall immunocompromised state and recent surgical intervention placed him at higher risk of Enterococcus faecalis infection. Enterococcus faecalis bacteremia is a common cause of IE that has had no survival improvement in the past decade (2). Ultimately, his BAL culture was positive for Candida glabrata, which if resulted in fungemia, could be complicated by a rare but aggressive form of IE with a mortality rate of 80% requiring both medical and early surgical intervention (3). CONCLUSIONS: Triple valve endocarditis is rare with few studies in literature to guide the best management. Further research is necessary to identify patients at increased risk of multivalve IE, in regards to optimal screening methods to facilitate early detection and therapy. Reference #1: Kim, N., Lazar, J., Cunha, B., Liao, W., & Minnaganti, V. (2000). Multi-valvular endocarditis. Clinical Microbiology and Infection, 6(4), 207–212. doi: 10.1046/j.1469- 0691.2000.00065.x Reference #2: Dahl, A., Rasmussen, R. V., Bundgaard, H., et al. (2013). Enterococcus faecalis Infective Endocarditis. Circulation, 127(17), 1810–1817. doi: 10.1161/circulationaha.112.001170 Reference #3: Baddley, J. W., Benjamin, D. K., et al. (2008). Candida infective endocarditis. European Journal of Clinical Microbiology & Infectious Diseases, 27(7), 519–529. doi: 10.1007/s10096-008-0466-x DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alem Mehari, source=Web Response No relevant relationships by Lamiaa Rougui, source=Web Response

A structured approach to native mitral valve infective endocarditis: Is repair better than replacement?

OBJECTIVESMitral valve repair in native active infective endocarditis is technically challenging. The survival benefit over valve replacement is poorly established and possibly absent because of the high risk of repair failure and reoperation. In this study, we explore the results of our structured approach in these patients.METHODSBetween January 2000 and January 2017, 149 patients underwent surgery for native mitral infective endocarditis. Among them, 97 (66%) patients underwent valve repair and 52 (34%) underwent valve replacement. Our structured approach consisted of early surgery, radical resection of infected tissue, liberal use of prosthetic materials and ‘patch’ repair techniques. A critical assessment of expected repair durability was made intraoperatively and repair was not performed if concerns of long-term durability existed. To study the effects of valve repair on overall survival, landmark analysis was performed.RESULTSIn-hospital mortality was 15.4% (14 repair vs 9 replacement patients; P = 0.642). There were no residual infective endocarditis cases or early reoperations. On Cox proportional hazards analysis, valve replacement was not inferior to repair within 1-year post-surgery [hazard ratio (HR) 1.134, 95% confidence interval (CI) 0.504–2.540; P = 0.76]. Beyond 1 year post-surgery, replacement was associated with decreased survival (HR 2.534, 95% CI 1.002–6.406; P = 0.049). There were no differences in freedom from recurrent infective endocarditis (P = 0.47) and mitral valve reintervention (P = 0.52).CONCLUSIONSActive mitral valve endocarditis remains a complex disease with significant early and late morbidity and mortality. A structured approach allows valve repair in two-thirds of patients. Clinical results could be improved by focussing on early surgery, prior to extensive valve destruction, to enable durable repairs and improve late outcomes.

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.

325 Does Quality of Transthoracic Echocardiogram (TTE) Impact Predictive Value in Detecting Infective Endocarditis (IE)? A Single Centre Experience

In patients with intermediate or high pretest probability of IE, initial evaluation with TTE and subsequent transesophageal echocardiogram (TEE) is recommended. Studies showing low sensitivity of TTE for native valve endocarditis are based on less advanced echo techniques, and do not consider quality of TTE. Recently, evidence have suggested that good quality study impacts on the negative predictive value (NPV) of TTE. This study sought to assess whether good quality TTE will have sufficient NPV value to rule out IE in the absence of high-risk clinical features. Echocardiograms from patients with both TTE and TEE ordered to assess for IE was reviewed. Quality of the TTE (good, adequate or technically-difficult) by echocardiographer was noted and whether vegetation was seen. 212 patients had TTE followed by TEE to assess for IE (Males 71.7%; 57.7±16years). 151 (71.2%) patients had a negative TTE, 32 (15.1%) were positive and 29 (13.7%) were indeterminate for vegetation. Vegetation was found on TEE in 17.2% of negative TTE and 17.2% of indeterminate TTE. 75% of patients who had a positive TTE went on to have a positive TEE. The overall NPV of TTE without factoring test quality was 81.1%. This increased to 83.6% in adequate and 90.9% in good quality study. Good quality TTE has a high NPV in ruling out native IE. False negative TTEs decrease substantially when study quality is taken into account. Further studies and quality standardization of TTE is required before this approach can be utilized in practice.