Prosthetic Valve Endocarditis Research Articles

Surgical Challenges in Infective Endocarditis: State of the Art.

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Clinical presentation, microbiology, and prognostic factors of prosthetic valve endocarditis. Lessons learned from a large prospective registry.

Prosthetic valve endocarditis (PVE) is a serious infection associated with high mortality that often requires surgical treatment. Study on clinical characteristics and prognosis of a large contemporary prospective cohort of prosthetic valve endocarditis (PVE) that included patients diagnosed between January 2008 and December 2020. Univariate and multivariate analysis of factors associated with in-hospital mortality was performed. The study included 1354 cases of PVE. The median age was 71 years with an interquartile range of 62-77 years and 66.9% of the cases were male. Patients diagnosed during the first year after valve implantation (early onset) were characterized by a higher proportion of cases due to coagulase-negative staphylococci and Candida and more perivalvular complications than patients detected after the first year (late onset). In-hospital mortality of PVE in this series was 32.6%; specifically, it was 35.4% in the period 2008-2013 and 29.9% in 2014-2020 (p = 0.031). Variables associated with in-hospital mortality were: Age-adjusted Charlson comorbidity index (OR: 1.15, 95% CI: 1.08-1.23), intracardiac abscess (OR:1.78, 95% CI:1.30-2.44), acute heart failure related to PVE (OR: 3. 11, 95% CI: 2.31-4.19), acute renal failure (OR: 3.11, 95% CI:1.14-2.09), septic shock (OR: 5.56, 95% CI:3.55-8.71), persistent bacteremia (OR: 1.85, 95% CI: 1.21-2.83) and surgery indicated but not performed (OR: 2.08, 95% CI: 1.49-2.89). In-hospital mortality in patients with surgical indication according to guidelines was 31.3% in operated patients and 51.3% in non-operated patients (p<0.001). In the latter group, there were more cases of advanced age, comorbidity, hospital acquired PVE, PVE due to Staphylococcus aureus, septic shock, and stroke. Not performing cardiac surgery in patients with PVE and surgical indication, according to guidelines, has a significant negative effect on in-hospital mortality. Strategies to better discriminate patients who can benefit most from surgery would be desirable.

Salmonella Enteritidis ST11 Prosthetic Valve Endocarditis Complicated by a Paravalvular Abscess: Case Report and Literature Review

Salmonella infection typically causes self-limiting gastroenteritis. However, in rare cases, it can lead to prosthetic valve endocarditis (PVE), especially in older adults with a history of valve replacement surgery. In this case study, we describe a case of Salmonella PVE in a man with a prosthetic aortic valve. Complications of PVE include abscess formation, which is associated with increased mortality. If a patient with a history of prosthetic valve replacement presents with symptoms suggestive of gastroenteritis or bacteremia, a thorough investigation should be conducted with suspicion of PVE. The prognosis of Salmonella PVE can be improved by promptly initiating appropriate antibiotics and administering them for an adequate duration, as well as by considering surgical intervention when necessary. Additionally, confirming negative blood cultures after treatment of Salmonella bacteremia is important to prevent the development of PVE and paravalvular abscesses.

Epidemiological and Molecular Investigation of the Heater-Cooler Unit (HCU)-Related Outbreak of Invasive Mycobacterium chimaera Infection Occurred in Italy.

From 2013 onwards, a large outbreak of Mycobacterium chimaera (MC) invasive infection, which was correlated with the use of contaminated heater-cooler units (HCUs) during open chest surgery, was reported from all over the world. Here, we report the results of the epidemiological and molecular investigations conducted in Italy after the alarm raised about this epidemic event. MC strains isolated from patients or from HCU devices were characterized by genomic sequencing and molecular epidemiological analysis. Through retrospective epidemiological analysis conducted between January 2010 and December 2022, 40 possible cases of patients infected with MC were identified. Thirty-six strains isolated from these patients were analysed by whole genome sequencing (WGS) and were found to belong to the genotypes 1.1 or 1.8, which are the genotypes correlated with the outbreak. Most of the cases presented with prosthetic valve endocarditis, vascular graft infection or disseminated infection. Among the cases found, there were 21 deaths. The same analysis was carried out on HCU devices. A total of 251 HCUs were found to be contaminated by MC; genotypes 1.1 or 1.8 were identified in 28 of those HCUs. To ensure patients' safety and adequate follow-up, clinicians and general practitioners were made aware of the results and public health measures, and recommendations were issued to prevent further cases in the healthcare settings. The Italian Society of Cardiac Surgery performed a national survey to assess the incidence of HCU-related MC prosthetic infections in cardiac surgery. No cases were reported after HCU replacement or structural modification and disinfection and possibly safe allocation outside surgical rooms.

Transcatheter aortic valve-in-surgical aortic valve for a patient with repeated healed endocarditis: a case report

BackgroundTranscatheter valve replacement is contraindicated in patients with active infective endocarditis. However, few reports suggest that it could be beneficial for high-risk surgical patients with healed infective endocarditis. Here, we report a case of a surgical transcatheter aortic valve in a patient with healed repeated prosthetic valve endocarditis using a stentless valve.Case presentationA 79-year-old female who underwent the Bentall procedure using a stentless valve and coronary artery bypass grafting for annuloaortic ectasia 22 years ago was hospitalized for stage II bioprosthetic valve failure. The patient had a history of prosthetic valve endocarditis three times: the first and second prosthetic valve endocarditis occurred 15 years ago, and the third prosthetic valve endocarditis occurred 3 years ago. The causative organisms were Campylobacter fetus and Enterococcus faecalis. With appropriate antibiotic therapy, the lesion was localized and healed completely without valve destruction; however, the patient developed rapid aortic regurgitation. Based on a review of the patient’s history of prosthetic valve endocarditis, the absence of signs of infection, and clinical findings of transesophageal echocardiography and computed tomography, a diagnosis of structural valve deterioration with healed infective endocarditis was made. Subsequently, a transcatheter aortic valve in a surgical aortic valve using a balloon-expandable type was performed, because the patient had a high surgical risk of 12.7%. The patient’s postoperative course was uneventful. At the 1-year follow-up, there were no signs of infection or valve abnormalities.ConclusionsTranscatheter valve replacement can be a treatment option for high-risk surgical patients with healed limited lesions in infective endocarditis.

Evolving Patterns of Infective Endocarditis: Insights from a Tertiary Healthcare Institute in Western India

Abstract Context: Infective endocarditis (IE) is a dynamic disease with high morbidity and mortality despite advancements in diagnostics, antimicrobial therapy, and surgery. India faces a complex situation due to changing factors such as host characteristics, diagnostic techniques, antibiotics, and aggressive surgical approaches. Monitoring local epidemiology is crucial for prompt recognition and treatment. However, studies on IE trends in India are scarce and outdated. Aims: To investigate the clinical, microbiological, predisposing conditions, echocardiographic characteristics, and treatment outcomes of IE patients admitted to a Tertiary Care Academic Institute in Western India. Settings and Design: This retrospective observational study was done in a 2011-bedded tertiary care referral hospital in Western Maharashtra, between June 2019 and May 2023. The records of all adult patients (age &gt;14 years) admitted during the study period with a definite diagnosis of IE, both native valve endocarditis and prosthetic valve endocarditis according to the modified Duke criteria, were included in the study. Baseline demographic data on age, sex, underlying heart disease, and predisposing conditions for bacteremia (infections, central venous catheters, surgeries, and invasive procedures) were collected. Subjects and Methods: The echocardiographic and microbiological findings, complications, treatment, and outcomes were noted. All blood cultures done for the diagnosis of IE were processed using standard methods to identify bacterial and fungal species and antimicrobial susceptibility profiles. For all the patients in this study, blood (5–8 mL per bottle) was collected in adult blood culture bottles using standard precautions and processed by a semiautomated blood culture system (BioMérieux, Marcyl̕ Etoile). Identification of causative organisms was performed by standard microbiological methods. Transthoracic and transesophageal echocardiography were performed to determine the location of vegetation, type of valve infected, and cardiac complications. Sample Size Calculation: Considering the Indian prevalence of IE to be 14.5% as observed by Gupta et al.,margin of error as 9%, and 95% of confidence level, the minimum required sample size calculated using WinPepi software (version: 11.65) for conducting the study was 59 patients. Statistical Analysis: Data was collected and entered into a database using Microsoft Excel. Data was represented as the frequency with percentage and Chi-square test (two-sample proportionality test) were applied for comparison of categorical variables. Quantitative data was summarized using mean and standard deviation and a two-sample t-test was applied to compare differences. P &lt; 0.05 was considered statistically significant. Results: The mean age in the study was 44.1 ± 10.6 years with a female preponderance (male:female – 0.85:1). Rheumatic heart disease (RHD) (44.3%) was the most common underlying heart disease etiology, whereas 33% of patients did not have any cardiac disease. Blood culture was positive in 34.9% of episodes, with the most common organisms being Gram-positive Staphylococci (38%). Medical complications such as congestive heart failure (CHF) and acute kidney injury were seen in 41.2% of patients, followed by cerebrovascular accident and stroke in 20.6%. The majority of patients, 61.9%, had received antibiotics before referral to our center. Thirty-seven (58.7%) patients underwent definitive surgery for IE. The total in-hospital mortality rate was 12 (19.1%). In the univariate analysis, younger patients (&lt;50 years) with CHF, diabetes mellitus, and Staphylococcus culture-positive IE were independent predictors of mortality. Conclusions: Over the past four decades, the landscape of IE in India has experienced noteworthy transformations. The disease profile of patients has shifted from predominantly older individuals with RHD to a rising number of younger patients with prosthetic valves or those without identified valvular conditions. Moreover, the yield of blood cultures has declined due to the increased utilization of antibiotics over the last two decades, although Staphylococcus species continue to be the most common organisms detected. Despite significant advancements in medical technology, the mortality rate remains unchanged. Our study provides compelling evidence to advocate for early surgical intervention, which holds the potential for improved outcomes.

Enterococcal Prosthetic Valve Infective Endocarditis Presenting as Complete Heart Block with Intramyocardial Abscess Causing Asystolic Cardiac Arrest

The extension of an intracardiac abscess causing complete heart block is a rare complication of infective endocarditis that is associated with a high mortality. Early identification of conduction abnormalities and a low threshold for suspecting infective endocarditis is crucial to provide prompt management to prevent intracardial extension of infection. We report a case of a patient presenting with complete heart block in the setting of profound hyperkalemia, and was then found to have enterococcal prosthetic valve endocarditis, which was complicated by an intracardiac aortic root abscess which led to asystolic cardiac arrest. The development of heart block in endocarditis serves as a marker for poor prognosis and can signify progression of infection. Management therefore requires immediate pacing, antibiotic delivery to lessen infectious burden, and evaluation for consideration of surgical options such as valve replacement. It is therefore recommended for patients with endocarditis complicated by conduction abnormalities or intracardial abscesses to be treated by a multi-disciplinary team consisting of cardiologists, cardiothoracic surgeons, and infectious disease specialists.

Microbiological and echocardiography characteristics in the prosthetic valve endocarditis patients

Objectives: The goal of the study was description the status of describe microbiological and cardiac injury characteristics through echocardiographic images in prosthetic valve endocarditis patients.&#x0D; Methods &amp; Results: Cross-sectional description of 64 prosthetic valve endocarditis patients at Hanoi Heart Hospital and Cardiology Institute - Bach Mai Hospital from June 2016 to August 2018. Aged 54.01±17.25 (18-84) years old, (60.9% male). Bacterial endocarditis was found in 50% of cases, the most common causative pathogens were Gr(+) bacteria 81.25% (26/32), Gr(-) bacteria 18.75%, multi drug resistant 22.73%. The results of antibiogram showed that Staphylococcus aureus and the group of Gr (-) bacteria had the highest antibiotic resistance. Echocardiographic characteristics of infective endocarditis mitral valve 57.8%, aortic valve 34.4%, in many valve sites very few (3.1%). Biological aortic valve (27.6%) lower than mechanical aortic valve (63.6%). The aortic valve had multiple vegetations (45.65%), size of vegetations was 11.3±4.26 (mm), periprosthetic aortic abscess and dehiscence at the lateral annulus (17.39%). Biological mitral valve (48.7%), mechanical mitral valve (51.3%). Mitral valve had multiple vegetations (60.66%), size of vegetations was 8.99±5.6 (mm), prosthetic valve with dehiscence at the lateral annulus (11.48%). Early infectious endocarditis postop was characterized by heart failure, reoperation and mortality higher than lated infective endocarditis (p&gt;0.05).&#x0D; Conclusions: The half of prosthetic valve endocarditis had bacterial evidence, common causative pathogens were Gram positives. Multi drug resistant due to staphylococcus aureus and Gram negatives. Prosthetic mitral valve endocarditis had the highest rate, followed by prosthetic aortic valve, endocarditis lesions in many valve sites were few. The Characteristics of prosthetic aortic valve werre periprosthetic aortic abscess and dehiscence at the lateral annulus, the mitral valve had multiple vegetations.

Surgery for Infective Endocarditis after Primary Transcatheter Aortic-Valve Replacement-A Retrospective Single-Center Analysis.

Between March 2016 and July 2019, ten patients underwent surgery due to prosthetic-valve endocarditis after TAVR. They were identified in our institutional database and analyzed. Infective endocarditis was diagnosed 17 ± 16 month after TAVR. Mean age was 79 ± 4.4 years. Microbiological detection showed 6/10 positive blood cultures for enterococcus faecalis. Median EuroScore II was 24.64%. The mean size of the surgically replaced aortic prosthesis was 23.6 ± 1.3 and that of the TAVR was 28.4 ± 2.3 mm. The surgically implanted aortic valves had a mean gradient of 8.5 ± 2.2 mmHg. One patient died in hospital due to septic multiorgan failure. After discharge, all patients survived with a mean follow-up of 9 ± 8 month. With a rising number of patients after TAVR, prosthetic-valve endocarditis will increasingly occur in patients who were previously considered high or intermediate risk. Our results show that patients with TAVR infective endocarditis can be operated on with good results. Surgical therapy should not be withheld from TAVR patients with infective endocarditis.

Three Decades of Experience with Aortic Prosthetic Valve Endocarditis.

The objective of this study was to evaluate early and long-term outcomes of patients with aortic prosthetic valve endocarditis (a-PVE) treated with a prosthetic aortic valve (PAV), prosthetic valved conduit (PVC), or cryopreserved aortic homograft (CAH). A total of 144 patients, 115 male and 29 female, aged 67 ± 12 years, underwent surgery for a-PVE at our institution between 1994 and 2021. Median time from the original cardiac surgery was 1.9 [0.6-5.6] years, and 47 (33%) patients developed an early a-PVE. Of these patients, 73 (51%) underwent aortic valve replacement (AVR) with a biological or mechanical PAV, 12 (8%) underwent aortic root replacement (ARR) with a biological or mechanical PVC, and 59 (42%) underwent AVR or ARR with a CAH. Patients treated with a CAH had significantly more circumferential annular abscess multiple valve involvement, longer CPB and aortic cross-clamping times, and needed more postoperative pacemaker implantation than patients treated with a PAV. No difference was observed in survival, reoperation rates, or recurrence of IE between patients treated with a PAV, a PVC, or a CAH. CAHs are technically more demanding and more often used in patients who have extensive annular abscess and multiple valve involvement. However, the use of CAH is safe in patients with complex a-PVE, and it shows excellent early and long-term outcomes.

Aortic valve neocuspidization using bovine pericardium for prosthetic valve endocarditis in a hemodialysis patient

BackgroundHemodialysis patients are at high risk for prosthetic valve endocarditis (PVE) because of the risk of bacteria entering with each hemodialysis session. To avoid the use of artificial materials as much as possible, we performed aortic valve neocuspidization (AVNeo) using bovine pericardium.Case presentationA 67-year-old patient had undergone aortic valve replacement using a bioprosthetic valve 4 months previous. For the past month, he had had PVE caused by Candida glabrata. Because the pericardium had already been incised in the previous surgery and there was not enough pericardium left for neocuspidization, we performed AVNeo using bovine pericardium. The previously implanted bioprosthetic valve revealed sticky fungal warts on the leaflet and valve ring, which prevented the movement of the valves. We cut all of the threads holding the valve and removed the bioprosthetic valve. Three valves were cut from the bovine pericardium using a unique template following the method of Ozaki et al. and were fixed to the valve ring with a running suture. The postoperative course was good.ConclusionsWe believe that this treatment is an effective method for PVE because we can avoid the use of artificial materials as much as possible.

Pre-discharge 18F-Flourodeoxyglucose uptake pattern following transcatheter aortic-valve replacement and adverse prognostic features in aortic stenosis

18F-Flourodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) has been shown to be of utility in transcatheter aortic valve replacement (TAVR) patients with suspected prosthetic valve endocarditis. In the present study, we sought to analyze the relationship between 18F-FDG-PET/CT performed before discharge in TAVR patients and adverse prognostic features of aortic stenosis. We analyzed the association between 18F-FDG-PET/CT uptake pattern and degree of left ventricular mass index, aortic root dilatation, and aortic leaflet calcification extent. This is the first study to demonstrate that pre-discharge 18F-FDG-PET/CT in patients undergoing TAVR shows a significant negative correlation between 18F-FDG uptake pattern and adverse prognostic features.

Reoperative aortic root replacement for prosthetic aortic valve endocarditis: impact of aortic graft.

Existing aortic graft complicates the surgical management of prosthetic valve endocarditis (PVE); yet, its impact has not been well studied. We compared outcomes of patients with prior aortic valve replacement (AVR) versus aortic surgery plus AVR, who underwent reoperative aortic root replacement (ARR) for PVE of the aortic valve. All patients who underwent reoperative ARR for PVE between 2004 and 2021 from 2 aortic centres were included. Two groups were formed based on the presence/absence of aortic graft: prior aortic surgery (AO) and prior AVR (AV) alone. Inverse propensity treatment weighting matched the groups. The Kaplan-Meier method was used to analyse long-term survival, and Fine and Gray model was used to compare the cumulative incidence of reoperation. A total of 130 patients were included (AO n = 59; AV n = 71). After matching, AO patients had increased stroke incidence (12.4% vs 0.9%) and renal failure requiring dialysis (11.5% vs 2.5%). In-hospital mortality was comparable (21.5% AO and 18.6% AV). Survival over 5 years was 68.9% (56.6-83.8%) in AO and 62.7% (48.1-81.7%) in AV (P = 0.70). The cumulative incidence of reoperation was similar [AO 6.3% (0.0-13.2%) vs AV 6.1% (0.0-15.1%), P = 0.69]. Reoperative ARRs for prosthetic valve/graft endocarditis are high-risk procedures. AO patients had higher incidence of postoperative morbidity versus AV patients. For all patients surviving operative intervention, survival and reoperation rates over 5 years were comparable between groups.

Clinical Characteristics and Outcomes of Patients With Cutibacterium acnes Endocarditis

It is suggested that patients with Cutibacterium acnes endocarditis often present without fever or abnormal inflammatory markers. However, no study has yet confirmed this statement. To assess the clinical characteristics and outcomes of patients with C acnes endocarditis. A case series of 105 patients presenting to 7 hospitals in the Netherlands and France (4 university hospitals and 3 teaching hospitals) with definite endocarditis according to the modified Duke criteria between January 1, 2010, and December 31, 2020, was performed. Clinical characteristics and outcomes were retrieved from medical records. Cases were identified by blood or valve and prosthesis cultures positive for C acnes, retrieved from the medical microbiology databases. Infected pacemaker or internal cardioverter defibrillator lead cases were excluded. Statistical analysis was performed in November 2022. Main outcomes included symptoms at presentation, presence of prosthetic valve endocarditis, laboratory test results at presentation, time to positive results of blood cultures, 30-day and 1-year mortality rates, type of treatment (conservative or surgical), and endocarditis relapse rates. A total of 105 patients (mean [SD] age, 61.1 [13.9] years; 96 men [91.4%]; 93 patients [88.6%] with prosthetic valve endocarditis) were identified and included. Seventy patients (66.7%) did not experience fever prior to hospital admission, nor was it present at hospitalization. The median C-reactive protein level was 3.6 mg/dL (IQR, 1.2-7.5 mg/dL), and the median leukocyte count was 10.0 × 103/µL (IQR, 8.2-12.2 × 103/µL). The median time to positive blood culture results was 7 days (IQR, 6-9 days). Surgery or reoperation was indicated for 88 patients and performed for 80 patients. Not performing the indicated surgical procedure was associated with high mortality rates. Seventeen patients were treated conservatively, in accordance with the European Society of Cardiology guideline; these patients showed relatively high rates of endocarditis recurrence (5 of 17 [29.4%]). This case series suggests that C acnes endocarditis was seen predominantly among male patients with prosthetic heart valves. Diagnosing C acnes endocarditis is difficult due to its atypical presentation, with frequent absence of fever and inflammatory markers. The prolonged time to positivity of blood culture results further delays the diagnostic process. Not performing a surgical procedure when indicated seems to be associated with higher mortality rates. For prosthetic valve endocarditis with small vegetations, there should be a low threshold for surgery because this group seems prone to endocarditis recurrence.

Prognosis and follow-up of patients with prosthetic valve endocarditis treated conservatively in relation to WBC-SPECT imaging.

Our objective was to evaluate in patients with prosthetic valve endocarditis (PVE) treated conservatively, the prognostic value of white blood cell (WBC) signal intensity on SPECT and to describe the evolution of the WBC signal under antibiotics. Patients with PVE treated conservatively and positive WBC-SPECT imaging were identified retrospectively. Signal intensity was classified as intense if equal to or higher, or mild if lower, than the liver signal. Clinical, biological, imaging and follow-up information were collected from medical files. Among 47 patients, WBC signal was classified as intense in 10 patients and as mild, in 37. The incidence of the primary composite endpoint (death, late cardiac surgery, or relapse) was significantly higher in patients with intense vs. mild signal (90% vs. 11%). Twenty-five patients underwent a second WBC-SPECT imaging during follow-up. The prevalence of WBC signal decreased progressively from 89% between 3 and 6 weeks to 42% between 6 and 9 weeks and 8% more than 9 weeks after initiation of antibiotics. In patients with PVE treated conservatively, intense WBC signal was associated with poor outcome. WBC-SPECT imaging appears as an interesting tool for risk stratification and to monitor locally the efficacy of antibiotic treatment.

Aortic valve replacement after previous TAVI

Endovascular surgery for aortic valve defects has proven itself well in elderly patients with severe comorbidities competing with the underlying disease. However, the risk of dysfunction resulting from structural degeneration of bioprosthetic heart valve and prosthetic valve endocarditis remains high. Repeated surgeries are associated with complications, but open surgery is the only method of treatment in this group of patients.Objective: to describe a series of reinterventions for prosthetic valve dysfunction occurring after TAVI.Material and methods. From 2015 to 2022, at the Department of Emergency Surgery for Acquired Heart Diseases (Head, Professor R.M. Muratov), Bakulev Research Center for Cardiovascular Surgery, 6 reoperations were performed in patients who had previously undergone transcatheter aortic valve implantation (TAVI). The average age of patients at the time of TAVI and at the time of reoperation was 70.6 years (62–83) and 74.3 years (70–84), respectively. The EuroSCORE II predicted risk of mortality at the time of reintervention was 42.2% (21.7–87.6). The mean time to reoperation was 42 months. Indications for reoperation were early active prosthetic endocarditis (4 cases) and structural valve degeneration (2 cases).Results. At the hospital stage, 1 patient died of acute heart failure; the operation was performed for vital indications in conditions of extreme initial severity. In three patients, the early postoperative period was uneventful. One patient required intra-aortic balloon counterpulsation (IABP) due to heart failure, and 1 patient was implanted with permanent pacemaker. The average time of hospitalization was 14 days. Patients with active prosthetic endocarditis received a 6-week course of antibiotic therapy. The function of the implanted valves was satisfactory.Conclusions. Aortic valve replacement after previous TAVI is an emergency operation and represents the only way to treat valve dysfunction. Under active prosthetic endocarditis, timely surgery can save this patient cohort.

Impella Implantation as a Bridge to Surgery for Repair of Aorto-Right Ventricular Fistula Following Prosthetic Valve Endocarditis: A Case Report.

For patients with cardiogenic shock, delaying surgery with mechanical circulatory support is reported to yield better outcomes than emergency surgery. We report on an 82-year-old man diagnosed with vertebral osteomyelitis with concomitant infective endocarditis. Chest radiographs revealed a growing abscess, which resulted in an aorto-right ventricular fistula. Providing Impella support allowed for hemodynamic stabilization prior to surgery. The patient had an uneventful postoperative course and reported to be well in a follow-up 1 year later. Impella support can be used as a bridge to surgery for repairing fistulous tract formation in patients in cardiogenic shock.

Trichosporon inkin and Cutibacterium acnes bioprosthetic aortic valve endocarditis and prosthetic aortic root abscess with multi-focal emboli

This report presents the first case of a patient with dual pathogen-associated bioprosthetic aortic valve endocarditis, prosthetic aortic root abscess and multifocal septic emboli, caused by both Trichosporon inkin and Cutibacterium acnes. A 67-year-old male with a prosthetic aortic root replacement, bioprosthetic aortic valve and pacemaker presented with pyrexia, right arm numbness and confusion. Multiple left-sided embolic infarcts were found on brain imaging, eye examination was consistent with right-sided fungal endophthalmitis, and an aortic valve vegetation and aortic root abscess were visualised on trans-oesophageal echo. Pre-operative blood cultures were negative. Revision surgery tissue samples grew Trichosporon inkin and Cutibacterium acnes. Post-operatively, he was treated with 42 days of meropenem and 150 days of antifungals (ambisome plus flucytosine plus intravitreal voriconazole, followed by oral voriconazole), after which he was switched to long term oral suppressive therapy with doxycycline and fluconazole. Twelve months post operatively, he is well and there is no evidence of recurrence. Trichosporon prosthetic valve endocarditis has a 62% one-year mortality rate. This case presented additional complexity: dual infection with Cutibacterium acnes, multi-focal embolic disease, difficulty in obtaining a pre-operative microbiological diagnosis, and difficulty with antifungal treatment (toxicity risk, drug interactions, minimal evidence-based for treatment). Managing complex cardiothoracic infections involving prosthetic material, such as that described, requires a multi-disciplinary approach, involving cardiothoracic surgeons, infection specialists and pharmacists, and other allied health professionals if necessary, to optimise patient care and reduce morbidity and mortality.

The Role of 18F-FDG PET/CT for the Diagnosis of Prosthetic Valve Endocarditis

The use of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in diagnostic algorithms for prosthetic valve endocarditis (PVE) has increased since publication of studies and guidelines advocating its use. The assessment of test accuracy and factors contributing to test accuracy have been limited by small study sizes. To address the problem, this systematic review was undertaken using individual patient data (IPD) meta-analysis techniques. The primary objective was to estimate the summary sensitivity and specificity of 18F-FDG PET/CT in diagnosing PVE. It also assessed the effect of patient factors on these estimates.

18F-FDG PET/CT-derived total lesion glycolysis predicts abscess formation in patients with surgically confirmed infective endocarditis: Results of a retrospective study at a tertiary center

BackgroundAbnormal activity of 18F-FDG PET/CT is a major Duke criterion in the diagnostic work-up of infective prosthetic valve endocarditis (IE). We hypothesized that quantitative lesion assessment by 18F-FDG PET/CT-derived standard maximum uptake ratio (SURmax), metabolic volume (MV), and total lesion glycolysis (TLG) might be useful in distinct subgroups of IE patients (e.g. IE-related abscess formation).MethodsAll patients (n = 27) hospitalized in our tertiary IE referral medical center from January 2014 to October 2018 with preoperatively performed 18F-FDG PET/CT and surgically confirmed IE were included into this retrospective analysis.ResultsPatients with surgically confirmed abscess formation (n = 10) had significantly increased MV (by ~ fivefold) and TLG (by ~ sevenfold) as compared to patients without abscess (n = 17). Receiver operation characteristics (ROC) analyses demonstrated that TLG (calculated as MV × SURmean, i.e. TLG (SUR)) had the most favorable area under the ROC curve (0.841 [CI 0.659 to 1.000]) in predicting IE-related abscess formation. This resulted in a sensitivity of 80% and a specificity of 88% at a cut-off value of 14.14 mL for TLG (SUR).ConclusionWe suggest that 18F-FDG PET/CT-derived quantitative assessment of TLG (SUR) may provide a novel diagnostic tool in predicting endocarditis-associated abscess formation.