Previous Endocarditis Research Articles

Early Diagnostic Prediction of Infective Endocarditis: Development and Validation of EndoPredict-Dx.

Infective endocarditis is a life-threatening disease with diverse clinical presentations, making diagnosis challenging and requiring a range of complementary tests. The level of suspicion, based on clinical judgment, guides decisions regarding the initiation of empirical treatment and the selection of appropriate diagnostic tools. This study aimed to develop and validate the EndoPredict-Dx score for early prediction of infective endocarditis diagnosis. Patients admitted to a specialized cardiovascular hospital emergency department with suspected infective endocarditis between January 2011 and January 2020 were included. The primary outcome was left-sided infective endocarditis according to the Duke criteria. Logistic regression was used to derive the scoring system, with internal validation performed through bootstrapping. Candidate variables were obtained from the admission medical history, physical examination, and laboratory parameters. Of the 805 individuals with suspected infective endocarditis (median age 56 years (40-73); 58.6% men), 530 confirmed the diagnosis based on the Duke criteria. The EndoPredict-Dx assigned points for male sex, previous endocarditis, petechiae, heart murmur, suspected embolism, symptoms lasting 14 or more days at the time of admission, hemoglobin level ≤ 12 g/dL, leukocyte level ≥ 10 × 109/L, C-reactive protein level ≥ 20 mg/L, and urine red blood cells ≥ 20,000 cells/mL. Patients were divided into three risk groups. The AUROC was 0.78 (95% CI 0.75-0.81) for the derivation cohort and 0.77 for the internal validation. The EndoPredict-Dx score accurately predicted the likelihood of infective endocarditis using clinical and laboratory data collected at admission.

Frequency and Outcome of Postoperative Atrial Fibrillation Following Mitral Valve Replacement for Mitral Stenosis.

To determine the frequency and outcome of postoperative atrial fibrillation (POAF) in terms of in-hospital and 30-day mortality and morbidity after mitral valve replacement (MVR). Observational study. Place and Duration of the Study: Department of Cardiac Surgery, Northwest General Hospital and Research Centre, Peshawar, Pakistan, from September 2017 to March 2023. A total of 186 patients between the ages of 20 and 70 years, who had severe mitral stenosis and normal sinus rhythm and underwent MVR surgery, were included in the study. The frequency of POAF within 7 days following surgery and outcomes in terms of in-hospital and 30-day mortality / morbidity were recorded. POAF occurred in 19.4% patients. Patients with POAF were predominantly male (p = 0.01), aged over 50 years (p = 0.002), diabetic (p = 0.02), hypertensive (p = 0.02), had impaired LV function (p <0.001), enlarged LA (p = 0.003), pulmonary hypertension (p = 0.009), previous PMBV (p <0.001), and previous infective endocarditis (p <0.001). In-hospital and 30-day mortality rates were 7% and 8.6%, respectively. POAF patients had prolonged ICU stays (p <0.001), hospital stays (p = 0.04), and higher mortality rates (p <0.001). Persistent AF (22%) contributed to 30-day morbidity in the form of embolic stroke, limb ischaemia, and congestive heart failure. POAF commonly occurs following the MVR surgery and significantly impacts perioperative and 30-day morbidity and mortality. Postoperative atrial fibrillation, Mitral stenosis, Mitral valve replacement.

#1916 Infective endocarditis in young female hemodialysis patient: a case report and literature review

Abstract Background and Aims Infective endocarditis (IE) in hemodialysis patient is one of major infective and cardiovascular complications with high morbidity and mortality. Compared to general population, incidence of IE among hemodialysis (HD) patients is 50-60 times higher. Despite the devastating implications, there is no particular preventive measures of IE for HD patients. Previous studies revealed leading risk factors for IE in HD population including use of central venous catheters (CVCs), first 6 months period of renal replacement therapy (RRT), aortic valve disease, and previous endocarditis. Case Summary We report a case of IE in a 21-year-old female hemodialysis patient using AV fistula for the past 16 months with no prior history of heart valve disease, previous endocarditis, and IV drug abuse. Patient presented with fever of 38.5°C, dyspnea, and cough since three days before admission. Physical examination revealed grade 5 pansystolic murmur with punctum maximum at apex. Vegetation on the anterior mitral leaflet (AML) was first detected through trans-thoracal echocardiography. Patient was treated with ceftriaxone and vancomycin for 14 days, followed by oral antibiotics in outpatient setting after clinical resolution. Conclusion This case provides insight of the occurrence of IE in relatively young patient in the absence of well-known risk factors, making strict prevention, prompt diagnosis and treatment are of the utmost importance. Possible pathophysiological mechanisms for IE in HD patients are bacteremia from repeated vascular manipulation and valvular calcification that compromises valve to colonization. Therefore, besides infection prevention, managing the progression of valvular calcification among HD patients remains an issue to be addressed in future studies.

The Influence of Preoperative Neurological Complications on Outcomes after Surgery for Infective Endocarditis

Background. Infective endocarditis (IE) is considered a life-threatening cardiac infection with a predilection to involve heart valves. One of the most feared complications of IE is the development of new-onset neurological complications (NCs). The aim of this study is to compare the short- and long-term outcomes of surgery in patients with IE presenting with vs. without NCs. Methods. We retrospectively reviewed patient records which were regularly collected in our institutional database. Between January 2002 and August 2020, 438 consecutive patients who underwent open cardiac surgery in our university hospital due to IE were included in the retrospective study. Results. Of the total cohort, 89 patients (20.3%) had preoperative NCs. Patients in the NC group were more likely to be female (33.7% vs. 23.5%; P=0.049), had more acute kindly injury at presentation (22.5% vs. 10.0%; P=0.002), were more likely to be admitted to ICU (36.0% vs. 18.3%; P&lt;0.001), and had significantly more vegetations (84.3% vs. 69.8%; P=0.006) and overall higher preoperative embolization (92.1% vs. 11.7%; P&lt;0.001). Staphylococcus aureus as causative organism of IE was significantly higher in the NC group (35.2% vs. 16.1%; P&lt;0.001). Patients in the NC group had significantly higher affection of the mitral valve. There was no difference in postoperative outcomes between the two groups. The long-term survival was also similar in both groups. Preoperative atrial fibrillation (adjusted odds ratio (aOR): 2.03; 95% CI [1.04–3.93]; P=0.037) and Staphylococcus aureus IE (aOR: 2.60; 95% CI [1.4–4.8]; P=0.002) were independent risk factors of developing NCs, while previous endocarditis was a protective factor (aOR: 0.33; 95% CI [0.11–0.99]; P=0.048). Conclusion. Our study emphasizes the shared risk factors between mortality and developing NCs. NCs are critical in IE’s clinical presentation, but they do not independently predict short- or long-term survival following surgery for IE.

New Insights into Mortality-Related Risk Factors in Infective Endocarditis: Results from the Brandenburg State Endocarditis Register.

Endocarditis as a potentially life-threatening disease with high complication and mortality rates. In recent years, an increase in the incident of endocarditis has been reported throughout Europe. In the aging society, successful treatment is complex and challenging owing to the high rate of multimorbidity. We initiated a statewide prospective multicenter endocarditis registry in 2020. Perioperative risk factors, comorbidities, microbiological, laboratory and imaging diagnostics, complications, and mortality including 1-year follow-up were collected. The present midterm analysis includes factors influencing mortality in the first 313 patients. In-hospital mortality and 1-year mortality were 28.4 and 40.9%, respectively. Preoperative risk factors include age (p < 0.001), EuroSCORE II (p < 0.001), coronary artery disease (p = 0.022), pacemaker probe infection (p = 0.033), preoperative left ventricular ejection fraction (LVEF), systemic inflammatory response syndrome (SIRS), pulmonary edema, heart failure, septic emboli, acute renal failure, impaired coagulation, hypalbuminemia (p < 0.001), and N-terminal prohormone of brain natriuretic peptide (NTproBNP) (p = 0.001). The presence of peri-annular abscess, perforation, and shunt were associated with increased mortality (p = 0.004, 0.001, and 0.004, respectively). In addition, cardiopulmonary bypass time influenced mortality (p = 0.002). The main postoperative causes of death were multi-organ failure, renal failure, vasoplegia, and low-output syndrome (p < 0.001). Previous endocarditis was 7.7%, while 35.5% were prosthetic valve recipients and 33.6% were redo surgeries. Our first registry data show the complexity of endocarditis patients and the challenging treatment. Some risk factors can be treated preoperatively. For instance, hypalbuminemia and the duration of the procedure can be controlled with adequate albumin substitution and carefully planned procedures restricted to the essential requirements, that is, hybrid approaches with consecutive interventions.

Three Years’ Experience of the Infective Endocarditis Team in a University Hospital

Objective: Infective endocarditis is a serious disease with high morbidity and mortality due to serious embolic complications. The follow-up of the patients requires multidisciplinary evaluation. We aimed to share the experience of the infective endocarditis team in our hospital and to guide the work of the teams to be formed in the future. Methods: Our study was planned as descriptive, cross-sectional, and observational. The patients were diagnosed by the modified Duke criteria. The National Infective Endocarditis Consensus Report was considered during the diagnosis, follow-up, and treatment process. Results: Fifty (45.4%) of 110 patients followed by the team were diagnosed with endocarditis. Thirty of the patients (51.8%) were male, the median age was 63.5 (18-87) days, and the median duration of symptoms was 35.7 (1-180) days. 76% of the diagnoses were definite endocarditis, 46% of the cases had an acute course, aortic valve involvement was 38%, and native valve involvement was 60%; the most isolated agent was Stapyhylococcus aureus. Community-acquired infection was 46%. The most common predisposing factors were prosthetic heart valve (38%) and hemodialysis (46%). Fever was observed in 64% of the patients and dyspnea in 58%. The rate of detection of vegetation by transesophageal echocardiography was 68%. Brain, pulmonary embolisms, and spondylodiscitis were the most common complications. The median time for blood culture to become negative was 3 (3-15) days, the operation time for 15 patients was 8 (1-30) days, and the 30-day hospital mortality was 28%. A statistically significant correlation was found between mortality and the presence of previous endocarditis, ejection fraction below 50%, complication development, hospitalization in the intensive care unit, presence of thrombocytopenia, Charlson comorbidity index ≥5, and vegetation size ≥1 cm (p&lt;0.05). We determined that the presence of previous endocarditis increased the risk of mortality 14 times (p=0.025). Conclusion: Mortality and morbidity rates can be reduced by detecting underlying diseases, controlling complications, applying early effective antibiotic and anticoagulant treatment, surgical interventions at the right time, and rapid supportive treatments for sepsis by teams formed with a multidisciplinary approach.

Determinants of adherence to oral hygiene prophylaxis guidelines in patients with previous infective endocarditis

BackgroundInfective endocarditis (IE) is characterized by low incidence but high mortality. Patients with a history of IE are at highest risk. Adherence to prophylaxis recommendations is poor. We sought to identify determinants of adherence to oral hygiene guidelines on IE prophylaxis in patients with a history of IE. MethodsUsing data from the cross-sectional, single-centre POST-IMAGE study, we analysed demographic, medical and psychosocial factors. We defined patients as adherent to prophylaxis if they declared going to the dentist at least annually and brushing their teeth at least twice a day. Depression, cognitive status and quality of life were assessed using validated scales. ResultsOf 100 patients enrolled, 98 completed the self-questionnaires. Among these, 40 (40.8%) were categorized as adherent to prophylaxis guidelines, and were less likely to be smokers (5.1% vs. 25.0%; P=0.02) or have symptoms of depression (36.6% vs. 70.8%; P<0.01) or cognitive decline (0% vs. 15.5%; P=0.05). Conversely, they had higher rates of: valvular surgery since the index IE episode (17.5% vs. 3.4%; P=0.04), searching for information on IE (61.1% vs. 46.3%, P=0.05), and considering themselves as adherent to IE prophylaxis (58.3% vs. 32.1%; P=0.03). Tooth brushing, dental visits and antibiotic prophylaxis were correctly identified as measures to prevent IE recurrence in 87.7%, 90.8% and 92.8% of patients, respectively, and did not differ according to adherence to oral hygiene guidelines. ConclusionsSelf-reported adherence to secondary oral hygiene guidelines on IE prophylaxis is low. Adherence is unrelated to most patient characteristics, but to depression and cognitive impairment. Poor adherence appears related more to a lack of implementation rather than insufficient knowledge. Assessment of depression may be considered in patients with IE.

Abstract 11101: Q Fever Endocarditis Combined With Thrombus and Antiphospholipid Syndrome

A 63-year-old-man presented to our institution with dyspnea. Transthoracic echocardiography (TTE) showed severe degenerative aortic stenosis with regurgitation and decreased left ventricular contractility. Subsequent transesophageal echocardiography (TEE) and cardiac computed tomography (CT) revealed an outpouching structure at aortomitral intervalvular fibrosa (AMIVF) (Fig A to D), which was compatible with pseudoaneurysm and suggested sequelae of previous infective endocarditis. On surgery, thickened AV leaflets were noted, especially on NCC and LCC (Fig E). When extracting the AV leaflets, subannular pouching was seen without evidence of active inflammation or infection (Fig F). AV replacement with 25-mm Sorin Mitroflow was performed.One-year TTE follow-up showed markedly increased transAV pressure gradient. TEE and cardiac CT revealed symmetric nodular thickening of bioprosthetic AV leaflets with opening limitation (Fig G to J). The patient was admitted on the diagnosis of subclinical bioprosthetic valve thrombosis, and anticoagulation with warfarin and aspirin was started. During the hospitalization, the patient had persistent fever with bicytopenia and hepatosplenomegaly, but repetitive blood cultures were negative. There was no definite fever focus even in 18F-FDG PET CT (Fig K). Since the patient worked on a farm in Dangjin, Chungcheongnam-Do, South Korea, where Q fever is prevalent, an indirect immunofluorescence assay for Coxiella burnetii was conducted and the result turned out to be positive. Additional coagulopathy laboratory findings showed positive for lupus anticoagulant, anti-cardiolipin IgM, and anti-beta2 GPI IgM. Finally, the patient was diagnosed with Q fever endocarditis combined with antiphospholipid syndrome and treated with doxycycline with hydroxychloroquine and maintained anticoagulation. Recent follow-up of TTE and cardiac CT showed complete resolution of prosthetic AV thrombus.

Is Less Always More? A Prospective Two-Centre Study Addressing Clinical Outcomes in Leadless versus Transvenous Single-Chamber Pacemaker Recipients.

(1) Background: Leadless (LL) stimulation is perceived to lower surgical, vascular, and lead-related complications compared to transvenous (TV) pacemakers, yet controlled studies are lacking and real-life experience is non-conclusive. (2) Aim: To prospectively analyse survival and complication rates in leadless versus transvenous VVIR pacemakers. (3) Methods: Prospective analysis of mortality and complications in 344 consecutive VVIR TV and LL pacemaker recipients between June 2015 and May 2021. Indications for VVIR pacing were “slow” AF, atrio-ventricular block in AF or in sinus rhythm in bedridden cognitively impaired patients. LL indication was based on individualised clinical judgement. (4) Results: 72 patients received LL and 272 TV VVIR pacemakers. LL pacemaker indications included ongoing/expected chronic haemodialysis, superior venous access issues, active lifestyle with low pacing percentage expected, frailty causing high bleeding/infectious risk, previous valvular endocarditis, or device infection requiring extraction. No significant difference in the overall acute and long-term complication rate was observed between LL and TV cohorts, with greater mortality occurring in TV due to selection of older patients. (5) Conclusions: Given the low complication rate and life expectancy in this contemporary VVIR cohort, extending LL indications to all VVIR candidates is unlikely to provide clear-cut benefits. Considering the higher costs of LL technology, careful patient selection is mandatory for LL PMs to become advantageous, i.e., in the presence of vascular access issues, high bleeding/infectious risk, and long life expectancy, rendering lead-related issues and repeated surgery relevant in the long-term perspective.

Aortic Valve Surgery in Patients with Infective Endocarditis: Mid-Term Follow-up of Patients Treated With the ST. Jude Medical Trifecta Valve.

It is particularly difficult to choose the appropriate prosthesis to treat infective endocarditis. To investigate the outcomes after aortic valve replacement with a stented bioprosthesis (Trifecta) in patients with active or previous infective endocarditis. We performed a single-centre, retrospective study including consecutive patients with infective endocarditis who underwent aortic valve replacement between July 2011 and June 2019. Survival and reintervention were assessed as of December 2021. Hospital mortality was defined as death in-hospital or within 30-days of surgery. Kaplan-Meier method was used for time-to-event outcome assessment (all-cause mortality and reoperation). Data are median (minimum and maximum) or absolute (relative) frequencies. We included 51 patients, median age of 69 (40 to 87) years, 78% male. The median follow-up time was 5.4 years and the maximum was 10 years. Most patients (71%) had native valve infective endocarditis and 16% had previous endocarditis. Surgery was urgent in 82%. Hospital mortality occurred in 10 patients (20%). After excluding these patients, 1-, 3-, 6-, and 9-years cumulative survival rates were 93%, 78%, 72%, and 72%, respectively. There were five bioprosthesis-related reoperations: 4 due to endocarditis at 1-year, 3-years, and 5-years on follow-up (n=1, 1 and 2, respectively) and 1 due to non-structural deterioration, 6-years after surgery. Despite the small sample size, this report supports a satisfactory performance profile of the Trifecta bioprosthesis in the treatment of infective endocarditis.

Outcomes in pregnant women with valvular heart disease from sub Saharan Africa transferred to a developed nation. A distinct care model

Abstract Background Pregnant women with valvular heart disease (VHD) in African countries still bear a disproportionate burden of maternal morbidity and mortality, due to the reduced accessibility to health care and the scarcity of skilled professionals. It is unclear if outcomes would be improved by care-delivery model changes. Purpose We performed a clinical audit of African pregnant women with VHD who were transferred for their care from five countries to our cardio-obstetrics unit, during a twenty-year period, through a memorandum of agreement of international cooperation. Methods A retrospective analysis of 81 pregnancies (P) in 45 African women with VHD (median age 24, IQR 22–29 years) from 2001 to 2020. The main outcome measures were major maternal complications and perinatal outcome. Results History of rheumatic heart disease was determined in 74.1% of the P. Most women were in NHYA I or II before P (79.0%), 43.2% had previous cardiac medication and 60.5% were anticoagulated (33.3% with acenocoumarol and 27.2% with warfarin). 59.3% of P had at least one valvular prosthesis, including 38 mechanical prosthetic valve (MPV) and 10 biological valves. 22.2% had prior surgical or percutaneous VHD correction, excluding prosthesis implantation. At baseline, impaired left ventricular ejection fraction was found in 12.3%. Previous arrhythmic event, stroke or infectious endocarditis were found in 12.3%, 8.6% and 6.2% of P, respectively. During P, deterioration in NYHA functional class occurred in 42.0% and 9.9% required initiation or intensified cardiac medication. For MPV, 51% maintained a vitamin K antagonist, 15.7% used LMWH from 6 to 12th weeks and 9.8% used LMWH throughout P. Valve thrombosis occurred in 4 women (4.9% of P), with one maternal death in a patient with double MPV. Hemorrhagic complications happened in 8.6% of P, all anticoagulated, in immediate postpartum or puerperal period. The 81 P resulted in 56 live births (69.1%), with a medium birth weight of 3026±471g. Delivery by caesarean section was performed in 28.3% of newborns. The incidence of miscarriage was 23.5% and fetal malformations occurred in 14.8%, with warfarin embryopathy in 4 cases. In univariate analysis, the presence of valvular protheses (p=0.001), and anticoagulation (p=0.001) were related to unsuccessful P. In multivariate analysis, VKA therapy was the unique independent predictor of unsuccessful P (p=0.048). Conclusion With the multidisciplinary care provided, pregnancy was relatively well tolerated and successful for women transferred from sub–Saharan Africa. However, the presence of a valvular prothesis is associated with unsuccessful pregnancy even in a developed nation. Efforts other than the implantation of a MPV should be pursued vigorously in sub Saharan Africa. Funding Acknowledgement Type of funding sources: None.

Sex-Specific Risk Factors for Short- and Long-Term Outcomes after Surgery in Patients with Infective Endocarditis.

(1) Background: Surgery for infective endocarditis (IE) is associated with considerable mortality and it is controversial whether the female gender is predictive for a worse outcome. This large single-center study investigated the impact of sex on outcomes after surgery for IE. (2) Methods: 413 patients (25.4% female) were included into this retrospective observational study. Univariate and multivariable analyses identified sex-specific risk factors for 30 day and late mortality. Survival was estimated by the Kaplan-Meier-method. (3) Results: Women presented more often with mitral valve infection (p = 0.039). Men presented more frequently with previous endocarditis (p = 0.045), coronary heart disease (p = 0.033), and aortic valve infection (p = 0.005). Blood transfusion occurred more frequently intraoperatively in women (p < 0.001), but postoperatively in men (p = 0.015) and men had a longer postoperative stay (p = 0.046). Women showed a higher 30 day mortality than men (p = 0.007) and female gender was predictive for 30 day mortality (OR 2.090). Late survival showed no sex-specific difference (p = 0.853), and the female gender was not an independent predictor for late mortality (p = 0.718). Risk factors for early and late mortality showed distinct sex-specific differences such as increased preoperative CRP level in women and culture-negative IE in men.

Ultrasonic Emulsification of Severe Mitral Annular Calcification During Mitral Valve Replacement

PurposeSevere mitral annular calcification (MAC) increases surgical complexity and is independently associated with increased operative mortality for mitral valve replacement (MVR). Recently we adopted ultrasonic emulsification/aspiration for annular decalcification to address these risks and describe our early experience with this new technology. DescriptionExcluding previous mitral valve surgery or endocarditis, 179 patients with MAC underwent MVR at a single institution between January 2015 and March 2020. Of these, 15 consecutive patients with severe MAC (≥50% of the annulus) underwent annular decalcification with ultrasonic emulsification/aspiration as an adjunct treatment during MVR from April 2019 to March 2020. EvaluationMean patient age was 68 ± 12 years, and 72% (n = 128) were female. Mean preoperative left ventricular ejection fraction was 60% ± 11%, and mean mitral valve gradient was 9.1 ± 4.4 mm Hg. Concomitant procedures included antiarrhythmia (n = 52), aortic valve replacement (n = 32), and coronary artery bypass grafting (n = 20). There were no operative deaths or strokes in the group undergoing ultrasonic emulsification and aspiration. ConclusionsThe use of ultrasonic emulsification and aspiration in severe MAC patients may help mitigate the risks of MVR and facilitate operative success in this challenging, high-risk population.

Surgical and Transcatheter Pulmonary Valve Replacement: A Single Institution Comparison

Background and Hypothesis: Pulmonary valve replacement (PVR) is one of the most commonly performed procedures for patients with congenital heart disease. Transcatheter-based PVR (TPVR) approaches have emerged as alternatives to surgical pulmonary valve replacement (SPVR), but few studies have directly compared clinical outcomes between the two interventions. Further characterization of performance between the two valve procedures may inform clinical decision-making. &#x0D; Project Methods: Using institutional databases, we identified patients aged ≥ 9 years who underwent either a TPVR or SPVR at Riley Hospital for Children between January 2009 and June 2020. Exclusions were made for previous endocarditis diagnosis, &lt;1 year follow-up, and concomitant left heart procedures. Valve dysfunction was defined as ≥ moderate regurgitation or gradient ≥ 40 mmHg. &#x0D; Results: 94 (TPVR, n=52; SPVR, n=42) patients met inclusion criteria. Average follow-up for SPVR and TPVR patients was 5.1(2.0,6.7) and 2.9(1.6,4.8) years, respectively (p=0.007). The SPVR cohort was younger, had lower BMI, and underwent more prior sternotomies. Hospital length of stay was shorter after TPVR (1.0 day vs. 5.0 days, p&lt;0.001). Despite being younger, BSA-indexed valve size was larger in the SPVR cohort (14.7 mm/m2 vs 12.9 mm/m2, p&lt;0.001). Short-term mortality (0% vs 2%, p=0.36), endocarditis (0% vs 6%, p=0.11), and reintervention (12% vs 8%, p=0.49) did not differ between groups. Intermediate-term valve dysfunction/failure was greater in SPVR patients (29% vs 12%, p=0.04) with time to dysfunction 809(421,1565) and 1184(181,1627) days for SPVR and TPVR, respectively. Valve implantation failure due to pre-stent migration occurred in 4% of TPVR cases; one required surgical intervention. &#x0D; Conclusion and Potential Impact: In patients undergoing PVR at our institution, rates of mortality and infective endocarditis are similar between interventions. Intermediate-term valve dysfunction/failure was greater in SPVR cohort, but length of follow-up was significantly longer in these patients. Reintervention rates were similar between procedures.

Infective endocarditis and oral health-a Narrative Review.

Infective endocarditis is a rare but usually severe and often fatal inflammatory disease affecting the endocardial surface, native and prosthetic valves or cardiac devices. Besides various staphylococcus species, oral viridans streptococci are known to play a crucial role in the development of endocarditis, especially in patients with underlying cardiac conditions, such as valve replacement, congenital heart disease and a history of previous infective endocarditis. Particularly undetected persisting odontogenic infections and their secondary symptoms, as well as various therapeutic measures for their prevention and treatment, may lead to bacterial transfer from the oral cavity into the bloodstream, eventually enabling bacterial adherence to endocardial surfaces and thus promoting infective endocarditis. The administration of antibiotics prior to dental interventions in order to prevent this mechanism was initially recommended almost seventy years ago and has been the subject of research and intensive discussion ever since. Recently, numerous professional societies worldwide have published guidelines and updates on the prevention of endocarditis with divergent recommendations regarding the requirement of prophylactic antibiotic regimen prior to dental procedures. The objective of this article was therefore to review the currently available literature regarding oral health and infective endocarditis and to examine the rationale behind the inconsistent recommendation situation, critically.

Paravalvular leaks: short and long-term outcomes of surgical versus percutaneous closure

Abstract Introduction Paravalvular leaks (PVL) appear in 5–17% of patients who undergo surgical valve replacement, causing heart failure (HF), haemolytic anaemia, or both in 2–5% of cases. Surgical intervention (SI) is the first line treatment, although transcatheter intervention (TI) is gaining ground as an alternative. However, there are no randomized studies comparing both techniques. Purpose The aim of this study is to compare the short and long-term outcomes in patients with symptomatic PVL undergoing SI or TI. Methods We conducted a retrospective analysis of all patients who underwent SI or TI for PVL between 2004 and 2020 in our institution. The primary endpoint (PE) was the composite of cardiovascular mortality, readmission for HF and reintervention for PVL up to 24 months after the procedure. The secondary endpoints were admission length, technical and procedural success, and rate of complications. The definition of technical success was the correct placement of the device with no impaired function of the valve prosthesis and with ≤ grade II residual regurgitation. Procedural success was defined when there was technical success with no presentation of intervention-related complications. Results Picture 1 provides information about the clinical and procedural characteristics, initial outcome and outcome during follow-up. A total 85 procedures, 39 transcatheter (45.9%) and 46 surgical (54.1%), were performed on 67 patients. The patients who underwent TI were older (67.5 versus 61.4 years; p=0.03) had a worse functional class (NYHA III-IV 100% versus 80%; p=0.02), a lower frequency of previous endocarditis (22.2% versus 52.2%; p=0.03) and higher surgical risk (EuroScore 18.7 versus 10.4 and EuroScore II 8.6 versus 5.6; both p=0.001). The hospital stay was significantly shorter for TI (10.2 versus 30.4 days; p=0.009). Additionally, although without statistical significance, there was a lower frequency of complications (41% versus 58.7; p=0.16) and less technical success (69.2% versus 86.7%; p=0.052). There were no differences between procedure success (61.5% versus 71.1%, p=0.49). Regarding PE, at 24 months there were no differences in event-free survival (TI 55.9% versus SI 64.1%; Log-Rank p=0.8) (Picture 2). Conclusion The main finding of our study was the absence of significant differences in the short and long-term outcomes (composite of cardiovascular mortality, readmission for HF and reintervention) between surgical versus percutaneous closure. In conclusion, transcatheter intervention must be considered as a good alternative, particularly in high-risk surgical patients. Funding Acknowledgement Type of funding sources: None. Picture 1. Baseline characteristicsPicture 2

Clinical predictors of outcome in patients with infective endocarditis receiving outpatient parenteral antibiotic therapy (OPAT)

Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat infective endocarditis (IE) with documented success. This study aims to identify risk factors for treatment failure and poor outcomes in patients with IE treated through OPAT. We conducted a retrospective analysis of all episodes of IE treated over 13 years (September 2006 - September 2019) at a large teaching hospital in Sheffield, UK. We defined OPAT failure as unplanned readmission or death within 30 days of discharge from the OPAT service. Major adverse cardiac events (MACE) were defined as a composite of IE-related death, cardiac surgery, and recurrence of IE within the first year of completion of OPAT. Overall, 168 episodes of IE were reviewed. OPAT failure and MACE occurred in 44 episodes (26.2%) and 29 episodes (17.3%) respectively. On multivariable analysis, pre-existing renal failure (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.08-8.30; P=0.034) and Charlson comorbidity score (aOR, 1.29 per unit increase; 95% CI, 1.06-1.57; P=0.011) were associated with increased risk of failure. Previous endocarditis (aOR, 3.60; 95% CI, 1.49-8.70; P=0.004) and cardiac complications (aOR, 3.85; 95% CI, 1.49-9.93; P=0.005) were risk factors for MACE, whereas cardiac surgery during the initial hospitalisation for IE (aOR, 0.34; 95% CI, 0.12-0.22; P<0.001) was a protective factor. Our findings suggest that OPAT is safe and effective for completing antibiotic treatment for IE, including cases deemed to be at increased risk of complications. However, careful patient selection and monitoring of patients with pre-existing comorbidities and cardiac complications are recommended to optimise clinical outcomes.

Fitness, body weight loss and inappropriate shocks of subcutaneous-implantable cardioverter-defibrillator – a case report.

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is a well-established method for the prevention of sudden cardiac arrest and an alternative to the transvenous implantable cardioverter-defibrillator (TV-ICD). It is preferred mainly for young patients with long life expectancy, high risk of transvenous lead complications or history of previous endocarditis, or device infections. For both S-ICD and TV-ICD, inappropriate therapies are possible. For S-ICD, the most common cause of inappropriate shocks is T wave oversensing (TWOS), while in TV-ICD – supraventricular tachycardia. We present the case of a 38-year-old patient who reported a shock during physical exercise - crunches.

Midterm Results of Isolated Tricuspid Valve Replacement—Implications for Clinical Decision Making

BackgroundIsolated tricuspid valve replacement (TVR) is considered high-risk surgery. We investigated our outcomes of TVR with the aim of identifying variables that may influence morbidity and mortality of isolated TVR compared with combined TVR and left-sided valve surgery. MethodsRetrospective analysis of patients undergoing TVR surgery. The primary endpoint was long-term mortality. The association of postoperative outcomes with isolated compared with combined replacement was analyzed. The association between type of surgery and mortality over time was evaluated using Cox proportional hazards regression models to estimate the hazard ratio. ResultsOverall, 70 patients underwent TVR. Mean age was 61 ± 12 years and 74% (52 of 70) were women. About two thirds (61%) of the study population had a diagnosis of rheumatic heart disease and 8% (6 of 70) had previous infectious endocarditis. Atrial fibrillation was prevalent (86%, 60 of 70). Comorbidities were similar between groups. Tricuspid valve replacement combined with left-sided valvular surgery was performed in 37 patients (53%), and isolated replacement in 33 patients (47%). Previous cardiac surgery was common (40 patients, 57%). One-month survival rate was 94.3% (66 of 70). During a median follow-up period of 3.6 years, 12 patients (17%) died. The cumulative 5-year survival tended to be lower among patients with isolated TVR compared with patients having combined surgery. ConclusionsWe showed that TVR can be performed with good outcomes. Isolated TVR did not increase morbidity and mortality when patients are referred for surgery early, including after previous sternotomy. This finding should perhaps lead to a more aggressive approach toward patients requiring isolated replacement.

Mycotic Hepatic Artery Aneurysm, a Rare Complication of Aortic Valve Endocarditis

Purpose: Mycotic hepatic artery aneurysms (MHAAs) are uncommon (less than 0.1%) and mainly affect the extrahepatic region. In most cases, MHAAs are asymptomatic and a high clinical suspicion is needed. Arteriography is the gold standard and it can be used as a diagnostic and therapeutic tool. MHAAs are associated with a high risk of rupture, even in patients without symptoms suggestive of MHAA or previous endocarditis. Thus, an early diagnosis and treatment is necessary. Surgery or endovascular techniques may be performed. The endovascular approach is accepted in intrahepatic MHAAs or in high risk patients. Methods: Below we present a case of MHAAs secondary to aortic valve endocarditis. Results: A 58-year-old male underwent an aortic valve replacement due to an acute aortic regurgitation for aortic valve endocarditis. The patient maintained febrile syndrome during the postoperative period, in spite of broad-spectrum antibiotics. The CT scan showed an aneurysmal dilatation (45 mm in diameter) on the right hepatic artery. The appearance of a rapidly growing aneurysmal lesion, which was observed in previous radiologic examinations, suggested a diagnosis of a mycotic aneurysm secondary to infective endocarditis. A selected angiography of the celiac trunk was performed, which confirmed the diagnosis. An endovascular approach was applied and an aneurysm coil embolization was performed. Targeted antibiotic therapy was applied during 6 weeks and the patient showed an improvement and was discharged. He is currently asymptomatic. Conclusion: High clinical suspicion and multidisciplinary early approach is necessary to achieve a satisfactory outcome in MHAAs.