Previous Endocarditis Research Articles

Impact of Mechanical Aortic Prostheses in hospital stay and anticoagulation related complications

Objective: Use of mechanical valves requires long-term anticoagulation, which carries additional risks of bleeding and thrombosis. The aim of the study was to investigate the impact of anticoagulation on length of postoperative stay and the incidence of anticoagulation-related complications. Methods: A multicentre study of prospectively collected data, including all patients below 65 years of age undergoing aortic valve replacement (± concomitant non-valvular procedures) was performed. Exclusion criteria included preoperative atrial fibrillation and other indications for anticoagulation, previous cardiac surgery, emergency operations and infective endocarditis. Primary end-points were length of hospital stay and anticoagulation-related complications within 6 weeks of discharge. Results: A total of 1973 patients were included over a 5-year period from 5 centres in the UK. Mean patient age was 59 years (range 17-65 years). Mechanical valves were implanted in 52% of patients. The use of mechanical prostheses was associated with significantly prolonged postoperative stay (median of 7 vs. 6 days with bioprosthesis, p 8 days; OR 1.55, 95% CI 1.27-1.90, p < 0.001). On subanalysis, 1.4% of patients with mechanical prosthesis required readmission for anticoagulation-related complications within 6 weeks of discharge (including late tamponade). An additional 2% required repeated hospital attendance for INR stabilisation. Conclusion: Use of mechanical valves in patients below 65 years of age is associated with both increased hospital stay and anticoagulation-related complications compared to bioprosthesis. The clinical and health economic implications of prosthesis choice should be considered by both the heart team and patient.

Streptococcus gallolyticus Bacteremia: An Experience from a Tertiary Center in South India.

IntroductionStreptococcus gallolyticus is an important cause of bacteremia and infective endocarditis in adults. Studies from other parts of the world have shown a strong association between S. gallolyticus bacteremia and colonic neoplasia. The profile of S. gallolyticus bacteremia is understudied in Indian population.Materials and methodsWe retrospectively analyzed the data of 16 patients with S. gallolyticus bacteremia obtained from microbiology registry. BacT/ALERT positive samples were inoculated into blood agar, chocolate agar, and MacConkey agar. Organisms were identified by the VITEK 2 microbial identification system, and susceptibility was done by the microbroth dilution method as per Clinical and Laboratory Standards Institute (CLSI) M100 guidelines. Clinical details were obtained from electronic medical records.ResultsMajority of our isolates were S. gallolyticus subspecies pasteurianus. Total 16 patients had S. gallolyticus isolated from blood over a 1 year period. The median age was 58 years (IQR: 46.5–66). Eleven were males; type II diabetes mellitus and chronic liver disease were the common comorbidities observed in our patients. None of our patients had underlying infective endocarditis or colonic malignancy. Penicillin sensitivity was 81.2% while all the isolates were susceptible to ceftriaxone. Ampicillin resistance was seen in only one of the isolates. In-hospital mortality was 12.5%.ConclusionStreptococcus gallolyticus subsp. pasteurianus is the commonest subspecies of S. gallolyticus isolated in our population. Unlike previous studies, colonic neoplasia and infective endocarditis were rare in our patients. Type II diabetes mellitus and chronic liver disease were the commonest risk factors identified in patients with S. gallolyticus bacteremia.How to cite this articleNiyas VKM, Arjun R, Sasidharan A, Palakunnath GA. Streptococcus gallolyticus Bacteremia: An Experience from a Tertiary Center in South India. Indian J Crit Care Med 2020;24(10):943–945.

Risk of New Bloodstream Infections and Mortality Among People Who Inject Drugs With Infective Endocarditis

People who inject drugs (PWID) who are being treated for infective endocarditis remain at risk of new bloodstream infections (BSIs) due to ongoing intravenous drug use (IVDU). To characterize new BSIs in PWID receiving treatment for infective endocarditis, to determine the clinical factors associated with their development, and to determine whether new BSIs and treatment setting are associated with mortality. This retrospective cohort study was performed at 3 tertiary care hospitals in London, Ontario, Canada, from April 1, 2007, to March 31, 2018. Participants included a consecutive sample of all PWID 18 years or older admitted with infective endocarditis. Data were analyzed from April 1, 2007, to June 29, 2018. New BSIs and factors associated with their development, treatment setting of infective endocarditis episodes (ie, inpatient vs outpatient), and 90-day mortality. The analysis identified 420 unique episodes of infective endocarditis in 309 PWID (mean [SD] patient age, 35.7 [9.7] years; 213 episodes [50.7%] involving male patients), with 82 (19.5%) complicated by new BSIs. There were 138 independent new BSIs, of which 68 (49.3%) were polymicrobial and 266 were unique isolates. Aerobic gram-negative bacilli (143 of 266 [53.8%]) and Candida species (75 of 266 [28.2%]) were the most common microorganisms. Ongoing inpatient IVDU was documented by a physician in 194 infective endocarditis episodes (46.2%), and 127 of these (65.5%) were confirmed by urine toxicology results. Multivariable time-dependent Cox regression demonstrated that previous infective endocarditis (hazard ratio [HR], 1.89; 95% CI, 1.20-2.98), inpatient treatment (HR, 4.49; 95% CI, 2.30-8.76), and physician-documented inpatient IVDU (HR, 5.07; 95% CI, 2.68-9.60) were associated with a significantly higher rate of new BSIs, whereas inpatient addiction treatment was associated with a significantly lower rate (HR, 0.53; 95% CI, 0.32-0.88). New BSIs were not significantly associated with 90-day mortality (HR, 1.76; 95% CI, 0.78-4.02); significant factors associated with mortality included inpatient infective endocarditis treatment (HR, 3.39; 95% CI, 1.53-7.53), intensive care unit admission (HR, 9.51; 95% CI, 4.91-18.42), and methicillin-resistant Staphylococcus aureus infective endocarditis (HR, 1.77; 95% CI, 1.03-3.03), whereas right-sided infective endocarditis was associated with a significantly lower mortality rate (HR, 0.41; 95% CI, 0.25-0.67). In this study, new BSIs were common in PWID receiving parenteral treatment for infective endocarditis. Discharging patients to outpatient treatment was not associated with an increase in new BSI incidence or mortality; carefully selected PWID may therefore be considered for such treatment.

Cardiovascular infections - recent progress and future challenges

Patients with previous endocarditis are at highest risk of infective endocarditis (266-fold compared to the general population) - preventive strategies are of particular importance in this patient subgroup. Patients with community-acquired E. faecalis bacteremia should undergo transesophageal echocardiography - according to a recent study the prevalence of endocarditis may be ≥ 20 % in this setting. Several smaller observational studies suggest an association between E. faecalis endocarditis and colorectal neoplasias - colonoscopy should therefore be offered to patients with newly diagnosed E. faecalis endocarditis (particularly in patients with unknown portal of entry). The non-inferiority of partial oral endocarditis treatment has been demonstrated in a selected subgroup of patients characterized by a stable condition/course, small vegetations and the absence of perivalvular complications. Uncritical and early oralisation of endocarditis treatment in patients not fulfilling these criteria may lead to adverse treatment outcomes. Approximately one out three patients with a left ventricular assist device (LVAD) will suffer from LVAD-related infections during the first year after implantation. Appropriate antibiotic treatment and adequate surgical debridement are essential management strategies.

Incidence of infective endocarditis caused by viridans group streptococci in Sweden – effect of cessation of antibiotic prophylaxis in dentistry for risk individuals

ABSTRACT Introduction In October 2012, the Swedish Medical Products Agency published new recommendations for the cessation of prophylactic antibiotics in dentistry for the prevention of infective endocarditis (IE). Previously, 2 g of amoxicillin per os would be administered 1 h before invasive dental procedures to patients with valve prosthesis, complicated heart valve disease, and to those with previous endocarditis. Objectives The aim of this study was to evaluate whether the total incidence of IE caused by oral viridans group streptococci (VGS) or IE caused by staphylococci, increased in Sweden after the introduction of the new recommendations. Methods The incidence of IE in Sweden before and after October 2012 was calculated and compared using an interrupted time series analysis. Separate analyses were conducted for the total incidence of IE, and IE caused by VGS or Staphylococcus aureus. Cases of IE were identified using the Swedish national registry of IE, which has existed since 1995 and contains data from all Swedish hospital clinics specialising in infectious disease. All cases with hospital admission date from the 1st of Jan 2008, to the 31st of Dec 2017 were included. The incidence calculations were corrected for annual changes in population size using data from the Swedish government agency Statistics Sweden. Results The results show no statistically significant increase in the slope of the trend line of the total incidence of IE, IE caused by VGS or S. aureus in the Swedish general population after October 2012, compared to before. Conclusion The results suggest that the recommended cessation of prophylactic antibiotics for the prevention of IE in dentistry has not led to an increased incidence of IE caused by oral streptococci among the Swedish population.

P1756 Predictors of outcome in mitral valve repair surgery

Abstract Background Surgical mitral valve repair currently remains a good option in both organic or functional mitral valve regurgitation (MVR). However, a significant number of patients (P) have comorbidities that can contribute to adverse outcomes. Objective To determine clinical and echocardiographic predictors of adverse outcomes in P submitted to MV repair surgery in our center, notably MVR recurrence and new MV replacement surgery or all-cause mortality. Methods Retrospective analysis of 262 P who underwent MV repair surgery between 2008 and 2017, with a mean follow-up of 30 months. P were included with both organic or functional MV regurgitation. P who underwent simultaneous coronary artery bypass grafting (CABG), atrial fibrillation (AF) surgery and tricuspid valve repair were also included. However, P with simultaneous surgical aortic valve replacement or previous endocarditis were excluded and the remaining 204 P were analysed. We evaluated whether MVR etiology, simultaneous surgery (tricuspid valve repair, AF or CABG), body mass index (BMI), gender, chronic obstructive pulmonary disease (COPD), diabetes mellitus, renal dysfunction (measured by serum creatinine levels), baseline left ventricular ejection fraction (LVEF) and left ventricle end-diastolic diameter (LVED) were predictors of a composite endpoint (follow-up MV replacement surgery or all-cause mortality) and secondary endpoints: MV replacement surgery and all-cause mortality. Results 204 P who underwent MV repair surgery, 67.2% male, mean age of 62 ± 14 years. 80.4% had organic MVR and 19.6% functional MVR (mostly ischemic – 72.4%). 7P (3.4%) had rheumatic MVR. 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation. 30-day mortality was 0%. The composite endpoint occurred in 40P (20%) and there was MVR recurrence with follow-up MV replacement surgery in 15P (7.5%) and all-cause mortality in 28P (13.7%). The authors found that elevated serum creatinine levels (OR 4.66; p = 0.003), COPD (OR 3.00; p = 0.035) and functional etiology (OR 2.22; p = 0.049) were predictors of the composite endpoint. Both COPD (OR 2.823; p = 0.024) and renal dysfunction (OR 6.901; p = 0.001) were also found to be independent predictors of all-cause mortality. Simultaneous CABG was a predictor of all-cause mortality (OR 2.82; p = 0.024). Female gender was a predictor of future MV replacement surgery (13.4% vs 4.7%, p = 0.023). However, echocardiographic variables (baseline LVEF and LVED) were not found to be significant predictors of adverse outcomes in MV repair surgery. Likewise, simultaneous AF or tricuspid valve surgery, rheumatic/ischemic etiology, high BMI or diabetes were not associated with poorer prognosis. Conclusion In P undergoing MV repair surgery, renal dysfunction and COPD were independent predictors of all-cause mortality. Functional etiology and simultaneous CABG surgery were also predictors of adverse outcomes. Baseline LVEF and LVED were not correlated with prognosis.

Pattern of antibiotic prophylaxis practice for dental procedures in children with congenital heart disease.

Various antibiotic prophylaxis guidelines have been published such as the American Heart Association 2007, British Society for Antimicrobial Chemotherapy 2006, National Institute for Health and Clinical Excellence 2008, European Society of Cardiology 2015, and in Malaysia, the National Antibiotic Guideline 2014 and Clinical Practice Guidelines for the Prevention, Diagnosis and Management of Infective Endocarditis 2017. The aim of the study is to determine the pattern of antibiotic prophylaxis practice for dental procedure in children with congenital heart disease (CHD) at the Department of Paediatric Dentistry, Kuala Lumpur Hospital. A comparative cross-sectional study of dental records from 2010 to 2015 was done by collecting data on the source and reason of referral, types of heart condition, dental procedure, and antibiotic given. There were 210 patients; 69.5% had acyanotic CHD, 21.9% cyanotic CHD, 6.7% repaired CHD with residual defects, and 1.9% with previous infective endocarditis. Slightly more than 58% were referred from government doctors (pediatric cardiologist and National Heart Institute). The common cause for referral was dental assessment (47.6%). Antibiotics were prescribed to 23.3% (49/210) patients, of which, 34.7% was given ampicillin or amoxicillin/clavulanic acid. About 96% of cyanotic heart cases undergoing invasive dental procedures were prescribed antibiotic prophylaxis. Almost 31% were prescribed with antibiotic prophylaxis even though it was not indicated. This study shows that there is variability in prescribing antibiotic prophylaxis, and it is important for dental clinicians to standardize the practice of giving antibiotic prophylaxis.

P1458 Recurrent endocarditis on mitral valve prosthesis

Abstract Patient Presentation and initial work up A 72 years old man with history of hypertension was admitted to our hospital due to acute pulmonary oedema. He had no fever at that time and he had an history of known mitral valve prolapse but with no reported mitral valve regurgitation (MR). Transthoracic Echocardiogram (TTE) was performed and it showed a severe MR. Transesophageal echocardiogram (TOE) showed prolapse of the posterior leaflet of the mitral valve with suspicion of cordal rupture and the presence of an aneurysm of the anterior mitral valve leaflet with perforation of it (panel A and B). Diagnosis and Management Diagnosis of severe MR as the result of previous endocarditis was made. Blood cultures were negative, as well as there were no signs of active endocarditis. However, since there were heart failure and signs of uncontrolled infection, the patient underwent surgical mitral valve replacement (MVR) with bioprosthesis. Moreover, it was started antibiotic therapy with vancomycin, rifampin and ceftriaxone, which was continued for two weeks and then stopped since the microbiological culture of the valve was negative. Follow-up After two months he was re-admitted to the hospital due to a new onset of breathlessness. TTE showed a dehiscence of the mitral prosthetic valve in the inferolateral zone with rocking movement, subvalvular pseudoaneurysm and moderate paravalvular leak (panel C and D). Blood cultures were positive for Staphylococcus Aureus. Consequently, the patient underwent a new surgical MVR. Furthermore, six weeks of antibiotic therapy were carried out with daptomycin and rifampin. However, after another three months, he was admitted once again to the hospital for heart failure with a new evidence of abruption of the mitral prosthesis, again in the inferolateral region and, this time, with the evidence of a vegetation on the atrial side of the prosthesis (panel E and F). Again, blood cultures were positive for Staphylococcus Aureus, and the patient underwent the third surgical intervention of MVR. Another six weeks of antibiotic therapy with daptomycin and rifampin were performed. The patient was then discharged and he is now strictly followed clinically. Conclusion In conclusion, we reported the case of a recurrent relapse of endocarditis on mitral valve prosthesis due to Staphylococcus Aureus infection. Interestingly, the mitral prosthesis was involved always in the same zone (inferolateral area) with abruption of the prosthesis and significant paravalvular regurgitation. At the second relapse there was also a vegetation on it and both times blood cultures were positive. Moreover, antibiotic therapy was conducted for six weeks both times, but the recurrence of endocarditis showed us that he was a sensitive patient and that in cases of relapses like this it should be performed a more careful clinical follow up, involving frequent laboratory tests and clinical and echocardiographic evaluations. Abstract P1458 Figure.

256. A Cross-Disciplinary Educational Approach: Antibiotic Prescribing Practices and the Use of Prophylactic Antibiotics Prior to Dental Procedures

BackgroundAntibiotics are frequently prescribed for prophylaxis prior to dental procedures. Little is known about the influences and beliefs among medical and dental practitioners regarding prophylactic antibiotic prescription prior to dental procedures among patients with prosthetic joints and those at risk for endocarditis.MethodsA cross-sectional electronic survey was designed and distributed among medical practitioners (physicians, APRNs and PAs in Primary Care, Cardiology, and Orthopedics), and dentists. The survey addressed the frequency of prophylactic antibiotic prescribing, factors influencing prophylactic antibiotic use, perceived responsibility for antibiotic prescribing and interest in further antibiotic-related education.ResultsAmong 336 survey recipients, 156 responded (response rate 46%), including 84 dentists and 72 medical practitioners. A higher proportion of dentists reported ≥1 prophylactic antibiotic prescriptions in the prior year compared with medical providers (79% vs. 58%). Most dentists (68%) believed that the dentist was responsible for prescribing the prophylactic antibiotic, whereas medical practitioners attributed this responsibility to the dentist (35%), the medical or surgical specialist (26%), or the primary care physician (38%). Dentists were more likely than medical practitioners to identify the following as indications for prophylactic antibiotics: poorly controlled diabetes mellitus (26% vs. 3%, P = 0.000), chronic kidney disease (8% vs. 0%, P = 0.041), cardiac transplant with valvopathy (61% vs. 40%, P = 0.023), and previous endocarditis (85% vs. 65% P = 0.005). Most medical providers (65%) and dentists (74%) reported interest in more education on prescribing antibiotics, with educational modules either online modules or email communications (58% and 54% of interested providers, respectively).ConclusionMedical providers and dentists frequently prescribe antibiotics prior to dental procedures. Beliefs regarding the responsibility and indications for prescribing varied by group and may not be consistent with published guidelines. Additional education, particularly through online or email, would be an opportunity to address the needs of these prescribers.Disclosures All authors: No reported disclosures.

Knowledge of infective endocarditis among dental students and interns in seven Nigerian Universities

Objective: Infective Endocarditis is a potentially life-threatening infection that could occur after an invasive dental procedure. It is usually associated with bacteria and high risk cardiac abnormalities. The depth of knowledge of infective endocarditic amongst dental students in developing countries is rarely reported and information relating to this is sparse in Nigeria. This study therefore aimed to determine the knowledge of IE amongst dental students and interns of Nigeria Universities. Methods: This cross-sectional study was conducted among dental students and interns of 7 Nigerian dental institutions using a self-administered questionnaire that captured biographic data, level of education, knowledge of Infective Endocarditis and sources of information. Data generated was analyzed using SPSS Windows version 20. Result: Two hundred and thirty-one students participated in the study. There were 120 males and 111 females, with M: F, 1.08: 1. Mean age was 25.34 ± 3.60 years. The participants were mainly in the age range of 22-25 years. Two hundred and nine (90.5%) participants knew that patients with prosthetic heart valve need prophylactic antibiotics prior to an invasive dental procedure and 204 (88.31%) responded that a positive history of previous endocarditis warrants prophylaxis. More than half knew that restoration of caries with amalgam need no prophylaxis. Knowledge of the type of antibiotics to administer was fair but none knew the right dose and the time of administration. Conclusion: Most participants had fair knowledge about conditions that require prophylactic antibiotics and the type of antibiotics. However, no one knew the dose and the time of administration. Keywords: Knowledge, infective endocarditis, dental students, antibiotic prophylaxis

Risk of Infective Endocarditis in Patients with End Stage Renal Disease.

Endocarditis is a serious complication in patients treated with RRT. The study aimed to examine incidence and risk factors of endocarditis in patients with ESRD. The Danish National Registry on Regular Dialysis and Transplantation contains data on all Danish patients receiving renal replacement (hemodialysis, peritoneal dialysis, or kidney transplantation) for ESRD. Incidence of endocarditis was estimated for each RRT modality. Independent risk factors of endocarditis were identified in multivariable Cox regression models. From January 1st, 1996 to December 31st, 2012, 10,612 patients (mean age 63 years, 36% female) initiated RRT (7233 hemodialysis, 3056 peritoneal dialysis, 323 pre-emptive kidney transplantation). Endocarditis developed in 267 (2.5%); of these 31 (12%) underwent valve surgery. The overall incidence of endocarditis was 627 per 100,000 person-years in patients receiving RRT. Incidence was higher in patients receiving hemodialysis compared with those receiving peritoneal dialysis or kidney transplantation (1092 per 100,000 person-years, 212 per 100,000 person-years, and 85 per 100,000 person-years, respectively). Adjusted hazard ratios for endocarditis in patients receiving hemodialysis were 5.46 (95% confidence interval [95% CI], 3.28 to 9.10) and 0.41 (95% CI, 0.18 to 0.91) for kidney-transplanted recipients, respectively, as compared with patients in peritoneal dialysis. The incidence of endocarditis in hemodialysis recipients with central venous catheters was more than two-fold higher as compared with those with arteriovenous fistulas. Overall mortality, subsequent to endocarditis, was 22% in-hospital and 51% at 1 year. The first 6 months in RRT, aortic valve disease, and previous endocarditis were identified as significant risk factors of endocarditis. Patients receiving RRT have a high incidence of endocarditis, in particular during hemodialysis treatment using central venous catheters. The first 6 months in RRT, aortic valve disease, and previous endocarditis are significant risk factors for developing endocarditis.

Antibioprophylaxie de l’endocardite infectieuse dans les cardiopathies congénitales

Infective endocarditis can negatively impact prognosis of congenital heart disease and has a 10-15% incidence of mortality. New guidelines recommend prophylaxis of infective endocarditis only for high-risk group (cyanotic congenital heart disease, valvular prosthesis, previous endocarditis) and for some specific invasive dental procedures. New guidelines are focused mainly on oral and cutaneous hygiene. Native shunts and valvular disease are no more targets for prophylaxis. More than half of the physicians do not follow the new guidelines. High-velocity shunts like ventricular septal defect should be included in the at-risk congenital disease for infective endocarditis where prophylaxis should be applied. The new guidelines for prophylaxis of infective endocarditis did not impact on the incidence of infective endocarditis.

23 Three year review of mitral valve surgery: predictability of mitral valve repair

Aims We aim to outline a three year review of consecutive mitral valve surgeries performed by a single surgeon. We further aim to establish the predictability of mitral valve repair in the degenerative population. Methods All patients who underwent isolated or combined mitral valve surgery from January 2013 to April 2016 had their pre operative echocardiograph and their operative note reviewed. In cases of degenerative disease this data was reviewed to compare predicted repair rates to actual repair rates. Results 181 patients underwent mitral valve surgery. Underlying pathologies were as follows; degenerative 57% (n = 103), functional/ischaemic 18.2% (n = 33), rheumatic 13.3% (n = 24), previous endocarditis 7.1% (n = 13), revision mitral valve surgery 4.4% (n = 8) and systolic anterior motion of the mitral valve 0.6% (n = 1). 78.5% (n = 142) of patients underwent mitral valve repair and 21.5% (n = 39) of patients underwent mitral valve replacement. 99.02% (n = 141) of patients with degenerative disease underwent a successful repair and 0.08% underwent mitral valve replacement. Conclusion Degenerative mitral valve disease remains the most common underlying pathology requiring mitral valve surgery. In high volume services, excellent repair rates can be achieved. This serves to further support the role of mitral valve surgery in patients with asymptomatic mitral valve disease.

Candida infective endocarditis: an observational cohort study with a focus on therapy.

Candida infective endocarditis is a rare disease with a high mortality rate. Our understanding of this infection is derived from case series, case reports, and small prospective cohorts. The purpose of this study was to evaluate the clinical features and use of different antifungal treatment regimens for Candida infective endocarditis. This prospective cohort study was based on 70 cases of Candida infective endocarditis from the International Collaboration on Endocarditis (ICE)-Prospective Cohort Study and ICE-Plus databases collected between 2000 and 2010. The majority of infections were acquired nosocomially (67%). Congestive heart failure (24%), prosthetic heart valve (46%), and previous infective endocarditis (26%) were common comorbidities. Overall mortality was high, with 36% mortality in the hospital and 59% at 1 year. On univariate analysis, older age, heart failure at baseline, persistent candidemia, nosocomial acquisition, heart failure as a complication, and intracardiac abscess were associated with higher mortality. Mortality was not affected by use of surgical therapy or choice of antifungal agent. A subgroup analysis was performed on 33 patients for whom specific antifungal therapy information was available. In this subgroup, 11 patients received amphotericin B-based therapy and 14 received echinocandin-based therapy. Despite a higher percentage of older patients and nosocomial infection in the echinocandin group, mortality rates were similar between the two groups. In conclusion, Candida infective endocarditis is associated with a high mortality rate that was not impacted by choice of antifungal therapy or by adjunctive surgical intervention. Additionally, echinocandin therapy was as effective as amphotericin B-based therapy in the small subgroup analysis.

80 Importance of 3D Tee in Procedure Success of Percutaneous Paravalvular Leak Closure

PurposeParavalvular leaks (PVL) are a recognised complication post surgery, but rarely result in heart failure and haemolysis. Redo surgery may present technical challenges and is associated with significant morbidity and...

Predictors of Clinical Success Among a National Veterans Affairs Cohort With Methicillin-Resistant Staphylococcus aureus Pneumonia

BackgroundThe treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is exceedingly complicated, which is concerning because of the high mortality rate associated with the infection. Identification of independent predictors of clinical success can optimize patient care by assisting clinicians in treatment decisions. ObjectivesOur goal was to identify independent predictors of clinical success in a national Veterans Affairs (VA) cohort of patients with MRSA pneumonia. MethodsA nested case-control study was conducted among a cohort of VA patients with MRSA pneumonia receiving linezolid or vancomycin between January 2002 and September 2010. Cases included those demonstrating clinical success, defined as discharge from the hospital or intensive care unit by day 14 after treatment initiation, in the absence of death, therapy change, or intubation by day 14. Control subjects represented nonsuccess, defined as therapy change, intubation, intensive care unit admission, readmission, or death between treatment initiation and day 14. The potential predictors assessed included treatment, patient demographic and admission characteristics, previous health care and medication exposures, comorbidities, and medical history. Odds ratios (ORs) and 95% CIs were calculated from logistic regression. ResultsOur study included 2442 cases of clinical success and 1290 control subjects. Demographic characteristics varied between the clinical success and nonsuccess groups, including age, race, and region of facility. A current diagnosis of chronic respiratory disease (46% vs 42%) and diagnosis of pneumonia in the year before the MRSA pneumonia admission (37% vs 32%) were both more common in the clinical success group. Despite these significant differences, only 2 predictors of clinical success were identified in our study: previous complication of an implant or graft, including mechanical complications and infections, in the year before the MRSA pneumonia admission (adjusted OR, 1.55 [95% CI, 1.17–2.06]) and treatment with linezolid (adjusted OR, 1.53 [95% CI, 1.12–2.10]). Predictors of nonsuccess (adjusted OR [95% CI) included diagnosis of concomitant urinary tract infection (0.82 [0.70–0.96]), intravenous line (0.76 [0.66–0.89]), previous coagulopathy (0.74 [0.56–0.96]), previous amputation procedure (0.72 [0.53–0.98]), current coagulopathy diagnosis (0.71 [0.53–0.96]), dialysis (0.54 [0.38–0.76]), multiple inpatient procedures (0.53 [0.45–0.62]), inpatient surgery (0.48 [0.41–0.57]), and previous endocarditis (0.24 [0.07–0.81]). ConclusionsMRSA pneumonia tends to affect patients with complex care, and identification of the predictors of clinical success is useful when considering different therapeutic approaches. In this national cohort of VA patients with MRSA pneumonia, treatment was the only modifiable variable predicting clinical success.

Valvular repair or replacement for mitral endocarditis: 7-year cohort study

A few studies have compared mitral valve repair and replacement in the setting of infective endocarditis, with varying results. We compared the characteristics and outcomes of mitral repair and replacement in endocarditis patients. All patients undergoing mitral valve repair or replacement for active mitral endocarditis during 2005-2011 were included. Operative and follow-up mortality, composite morbidity, recurrent endocarditis, and redo operations were prespecified endpoints for analyses. There were 25 and 35 patients undergoing mitral valve repair and replacement, respectively. They were followed-up for 3.9 ± 2.5 years. Valve replacement patients were older (p = 0.029), had a higher prevalence of intracardiac abscess (p = 0.035), previous endocarditis (p = 0.036), atrial fibrillation (p = 0.001), worse renal function (p = 0.013), higher risk scores (p = 0.004-0.020), and longer operation times (p < 0.001). Repair and replacement had similar rates of operative mortality (4.0% vs. 8.6%, p = 0.634), composite morbidity (16.0% vs. 28.6%, p = 0.357), survival (p = 0.564), recurrent endocarditis (p = 0.081), and redo operations (p = 0.813). Independent predictors of operative mortality were preoperative inotropic or intraaortic balloon pump support. The independent predictor of mortality during follow-up was dialysis. Independent predictors of composite morbidity were intracardiac abscess and hypercholesterolemia. The independent predictor of recurrent endocarditis was previous endocarditis, and the independent predictor of redo operation was previous stroke. Mitral valve replacement candidates had more baseline risk factors and higher raw rates of postoperative mortality and morbidity, which did not reach statistical significance.

Left ventricular to right atrial shunt (Gerbode defect): congenital versus acquired.

IntroductionCongenital left ventricular to right atrial (LV-RA) shunt (Gerbode defect) is rare, while acquired LV-RA shunt has been increasingly reported. As yet, systematically incorporated data of the LV-RA shunt have not been presented.AimTo present the clinical features, diagnostic challenge and management strategies of congenital and acquired LV-RA shunts.Material and methodsThe data source was based on a comprehensive literature retrieval of the LV-RA shunt in the period 1990–2013.ResultsIn comparison with the acquired Gerbode defect, the congenital Gerbode defect group of patients were younger and were associated more often with additional congenital disorders. Previous cardiac surgery and infective endocarditis were the two major aetiologies of the occurrence of the acquired shunts. Paravalvular abscess was associated in 10.2% and atrioventricular block in 13.6% of the acquired group patients. Transoesophageal echocardiography showed a higher diagnostic accuracy, lower missed diagnosis and lower inclusive diagnosis rates, in comparison to transthoracic echocardiography, but the misdiagnosis rates of the two modalities did not differ from each other. Four (4.5%) of the acquired group patients were complicated by atrioventricular block following surgical or interventional closure of the shunt. Eight (9.1%) patients died in the acquired group, but no patient died in the congenital group.ConclusionsThe diagnosis of an LV-RA shunt is quite challenging, especially in the context of coexisting abnormalities including an additional intracardiac shunt, tricuspid regurgitation, pulmonary artery hypertension and infective endocarditis, which have to be carefully differentiated from the shunt by further investigations. A better control of infective complications and careful manoeuvres during surgery may help to keep the LV-RA-sensitive septum intact.

TCT-682 Comparison of conventional surgery and transapical transcatheter approach for paravalvular leak closure in high risk patients: results from a single high volume institution.

Background: Paravalvular leaks (PVL)affect up to 17% of all surgically implanted prosthetic valves. Reoperation is associated with high morbidity and mortality. Transcatheter transapical (TA) closure is an emerging alternative for selected high-risk patients with PVL. The aim of this study is to compare the in-hospital outcomes of patients who underwent surgery and TA-closure for PVL in our single-center experience. Methods: From October 2000 and June 2013, 136 patients with PVL were treated in our Institution: 122 patients (89.7%%) underwent surgery (68% mitral-PVL; 32% aortic-PVL) and 14 patients (10.3%) underwent TA closure (all the pts had mitral PVL; 1 case had combined mitral and aortic PVLs). All the TA procedures were performed under general anesthesia in a hybrid operative room: in all but 1 case an Amplatzer Vascular Plug III device was utilized. Results: Baseline features of the patients were comparable in terms of age (p1⁄40.9), associated coronary artery disease (p1⁄40.6), chronic renal failure (p1⁄40.2), previous endocarditis (p1⁄40.08), concomitant atrial fibrillation (p1⁄40.4), while COPD was more prevalent in TA group (P1⁄40.002). Log-EuroScore was 15 11% and 19 8% in surgical and TA group respectively (p1⁄40.03). Most of the patients were in NYHA class III-IV (60% Vs 78%; p1⁄40.1); 41% of surgical patients and 86% of TA patients were at their second of more reoperation (p1⁄40.0001). Procedural success in TA group was 93% (1 conversion to surgery because of the dislocation of the device). Inhospital mortality was 10.6% in surgical group (all cardiac-related) and 0% in TA group (p1⁄40.08). Mean LOS was 19 days for surgery and 9 days for TA (p1⁄40.1). All the patients had less than moderate residual valve regurgitation after the procedure. Surgical treatment was identified as risk factor for in-hospital death at multivariate analysis (OR 1.6; p1⁄40.04). Conclusions: Transcatheter TA approach is a safe and effective therapeutic option in selected high-risk patients with PVL and it is associated with reduced risk of hospital mortality than surgical treatment, in spite of higher predicted risk. Further studies are needed to determine the long-term results of the two procedures.

Mitral valve perforation from aortic insufficiency

A 60-year-old man with a history of endocarditis presented with congestive heart failure New York Heart Association class III symptoms. He did not have any signs or symptoms of microembolic phenomenon and the blood cultures were negative. A transesophageal echocardiogram showed an eccentric jet of mitral regurgitation (MR) from a perforation in the anterior mitral valve leaflet (MVL) (Fig. 1, Video 1). There were no visible vegetations however; there was an eccentric jet of aortic insufficiency (AI) pointing directly against the point of anterior MVL perforation (Fig. 2, Video 2). Thus the primary lesion was AI from previous endocarditis with secondary involvement of the MV. The patient underwent mechanical mitral and aortic valve replacement. Intra-operative cultures of valve tissue were also negative and the pathology was consistent with fibrosis.