Prosthetic Valve Endocarditis Research Articles

Echocardiography in Infective Endocarditis: A High Hit Rate at Te Whatu Ora – Waitaha Canterbury

To evaluate the utility of echocardiography in General Medicine (GM) patients referred with possible infective endocarditis at Christchurch Hospital. Over a 6-month period between 1 January and 30 June 2021, all General Medicine in-patients who underwent echocardiography for any indication were screened to find those with possible infective endocarditis as an indication. This study reviewed the result of each echocardiogram and followed each patient over a 12-month period to determine the rate of infective endocarditis as the primary outcome. Secondary outcomes were the microbiological characteristics of those with infective endocarditis and operative rates. Of 262 GM patients who underwent echocardiogram during the study period, 88 (34%) patients were referred with possible endocarditis. Nineteen of 88 (22%) patients had definite or presumed infective endocarditis as a discharge diagnosis, comprising 12 (14%) patients with definite infective endocarditis, six patients with high clinical suspicion and non-diagnostic imaging who were treated as presumed endocarditis, and one patient with negative imaging subsequently readmitted with subacute prosthetic valve endocarditis. Five patients required operative management. Most of the culture-positive endocarditis in this series (70%) were from Streptococcus species; one had Staphylococcus aureus endocarditis. Approximately one in three echocardiograms performed on General Medicine patients at Christchurch Hospital are for possible infective endocarditis. A significant proportion of these patients are subsequently diagnosed with infective endocarditis. Given the scarcity of echocardiography, a case could be made for increasing resources and research into clinical predictive factors, which could further improve diagnostic rates.

A Rare Case of Q-Fever Prosthetic Valve Endocarditis

We present the case of a 32-year-old gardener with culture-negative chronic Q fever prosthetic valve endocarditis concomitant with another bacterial pathogen, leading to aortic root abscess formation, requiring a Bentall procedure, extracorporeal membrane oxygenation, and prolonged antimicrobial therapy, with a fatal outcome. Unique to this case, Q fever was identified early, and the second pathogen was only detected on 16S ribosomal RNA (rRNA) polymerase chain reaction of explanted valvular tissue. The findings included posthumous demonstration of severe aortitis and micro-abscesses contained in myocardial tissue.

Lactobacillus Endocarditis With Mixed Glomerulonephritis: A Case Report

We present a case of Lactobacillus prosthetic valve endocarditis with associated antineutrophil cytoplasmic antibody glomerulonephritis. A 41-year-old man presented with recurrent dark brown urine, lower-extremity rash, and acute kidney injury. Kidney biopsy confirmed the diagnosis of glomerulonephritis, with pathologic findings concerning for an infectious cause. Blood cultures returned positive for Lactobacillus species, and transesophageal echocardiogram findings were positive for prosthetic valve vegetation. Antimicrobial and low-dose steroid therapy were initiated to treat the endocarditis with confidence that resolution of his glomerulonephritis also would occur.

Twenty-Year Experience with Surgery for Native and Prosthetic Mitral Valve Endocarditis.

Background and Objectives: To evaluate the early and long-term results of surgical treatment of isolated mitral native and prosthetic valve infective endocarditis. Materials and Methods: All patients undergoing mitral valve repair or replacement for infective endocarditis at our institution between January 2001 and December 2021 were included in the study. The preoperative and postoperative characteristics and mortality of patients were retrospectively reviewed. Results: A total of 130 patients, 85 males and 45 females, with a median age of 61 ± 14 years, underwent surgery for isolated mitral valve endocarditis during the study period. There were 111 (85%) native and 19 (15%) prosthetic valve endocarditis cases. Fifty-one (39%) patients died during the follow-up, and the overall mean patient survival time was 11.8 ± 0.9 years. The mean survival time was better in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (12.3 ± 0.9 years vs. 8 ± 1.4 years; p = 0.1), but the difference was not statistically significant. Patients who underwent mitral valve repair had a better survival rate compared to patients who had mitral valve replacement (14.8 ± 1.6 vs. 11.3 ± 1 years; p = 0.06); however, the difference was not statistically significant. Patients who underwent mitral valve replacement with a mechanical prosthesis had a significantly better survival rate compared to patients who received a biological prosthesis (15.6 ± 1.6 vs. 8.2 ± 0.8 years; p < 0.001). Patients aged ≤60 years had significantly better survival compared to patients aged >60 years (17.1 ± 1.1 vs. 8.2 ± 0.9; p < 0.001). Multivariate analysis showed that the patient's age >60 years at the time of surgery was an independent risk factor for mortality, while mitral valve repair was a protective factor. Eight (7%) patients required reintervention. Freedom from reintervention was significantly higher in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (19.3 ± 0.5 vs. 11.5 ± 1.7 years; p = 0.04). Conclusions: Surgery for mitral valve endocarditis is associated with considerable morbidity and mortality. The patient's age at the time of surgery represents an independent risk factor for mortality. Mitral valve repair should be the preferred choice whenever possible in suitable patients affected by infective endocarditis.

C55 A GIANT PSEUDOANEURYSM OF MITRAL–AORTIC INTERVALVULAR FIBROSA PRESENTING AS RECENT–ONSET ANGINA AND CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION

Abstract A 66–year–old man was suddenly referred to the emergency department (ED) for an extra–hospital cardiac arrest due to ventricular fibrillation, promptly treated by a single DC shock. Four months prior, he had undergone aortic valve replacement with a biological valve prosthesis (BVP, Perimount Magna n. 23) for severe aortic stenosis. One month after cardiac surgery the patient was hospitalized for acute cholecystitis requiring antibiotics and percutaneous cholecystostomy. On arrival to the ED the patient was awake and completely asymptomatic; no fever during days before the episode. He had been complaining of constricting retrosternal chest pain during physical exertion for ten days. However, no signs of ischemia were seen on the EKG. TT echo showed a very large pulsatile anaechogenic area posteriorly to BVP. Transesophageal echocardiography (TEE 2D, Traditional 3D and TrueVue) highlighted a very large pseudoaneurysm of mitral–aortic interventricular fibrosa (P–MAIVF; Figures 1 and 2, long axis and short–axis views). TEE features included: 1) a very large cavity with thickened walls, extended for more than two–thirds of the prosthetic circumference and with multiple septa; 2) a large communication between the left ventricular outflow tract (LVOT) and P–MAIVF (see yellow dotted line in Fig.1A) with a to–and–fro flow into the cavity and a prominent systolic pulsation; 3) no paraprosthetic leak and absence of any attached mass or intraprosthetic aortic regurgitation. These findings suggested a prosthetic aortic valve endocarditis with an extensive periannular involvement. Moreover, the P–MAIVF may have led to “ab extrinseco” compression of the left coronary artery, with a potential role in the genesis of chest pain and ventricular arrhythmia (in absence of significant CAD at preoperative coronary angiography). An empiric antibiotic therapy with daptomycin and piperacillin–tazobactam was started. The patients subsequently underwent Bentall surgery with a subannular implantation technique (Perimount valvular prosthesis n.23 and Gelweave vascular prosthesis n.28). Figure 3 shows an intraoperative image and postoperative TEE. In conclusion, P–MAIVF is an ominous complication of prosthetic valve endocarditis. Presentation with exertional angina and cardiac arrest is unusual. TEE is sensitive for diagnosis and 3D echo provides better insights into the anatomy helping formulate an appropriate surgical strategy.

Association of early surgery and mortality in patients with native or prosthetic valve endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Background Infective endocarditis (IE) is a disease associated with high risk of morbidity and mortality. Recent studies suggests that surgery during index hospitalization may be performed without increased risk of mortality. However, differences in this association in patients with native valve IE and prosthetic valve IE remain unclear. Purpose The purpose of this meta-analysis is to explore differences in the association between early surgery and mortality in patients with native valve IE and prosthetic valve IE. Methods We performed a literature search for studies reporting an association between early surgery and study endpoints in patients with either native valve IE or prosthetic valve IE. The primary endpoint was in-hospital mortality. The secondary endpoints was long-term mortality. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Studies reporting mixed native and prosthetic valve populations were excluded. Results A total of 10 studies with 5493 participants (2505 with early surgery vs 2988 with conventional therapy) were included. The mean duration of follow-up was 55 months (ranging between 12 to 120 months). Early surgery in patients with native valve IE was associated with lower risk of in-hospital mortality (OR 0.48, 95% CI 0.28, 0.83; p&amp;lt;0.01). Early surgery in patients with native valve IE was associated with lower risk of long-term mortality, however this effect was primarily driven by a single study (OR 0.26, 95% CI 0.08, 0.83; p=0.02). Early surgery in patients with prosthetic valve IE was not significantly associated with risk of in-hospital mortality, however there is a trend toward lower risk (OR 0.77, 95% CI 0.58, 1.02; p=0.07). There was not enough studies reporting long-term outcomes to assess the association between early surgery and long-term mortality in patients with prosthetic valve IE Conclusions Early surgery is associated with lower risk of in-hospital mortality in patients with native valve IE and is not associated with increased risk of mortality in patients with prosthetic valve IE. Further high-quality studies are needed to elucidate the association between early surgery and long-term outcomes in both patients with native valve IE and prosthetic valve IE.

Prosthetic valve endocarditis secondary to Tropheryma whipplei in a patient with chronic polyarthritis

BackgroundWhipple’s disease is a chronic multisystemic infectious disease that rarely presents as culture-negative endocarditis. Most patients reported with Tropheryma whipplei endocarditis involve a native valve and few describe prosthetic valve disease.Case presentationA patient with chronic polyarthritis and previous mitral valve replacement developed decompensated heart failure without fever. Transesophageal echocardiography revealed a prosthetic mitral valve vegetation and he underwent prosthetic mitral valve replacement. Blood and prosthetic mitral valve cultures were unrevealing. Broad-range polymerase chain reaction (PCR) of the extracted valve and subsequent Periodic-acid-Schiff (PAS) staining established the diagnosis of T. whipplei prosthetic valve endocarditis.ConclusionWhipple’s disease may present as culture-negative infective endocarditis and affect prosthetic valves. Histopathology with PAS staining and broad-range PCR of excised valves are essential for the diagnosis. Greater clinical awareness and implementation of these diagnostic procedures should result in an increased reported incidence of this rare disease.

Long-term valve performance of St Jude Medical Epic porcine bioprosthesis in aortic position.

The aim of this study was to review long-term clinical outcomes and valve performance after Epic Supra valve implantation in aortic position. From 2011 to 2022, 44 patients (mean age 75 ± 8years) underwent surgical aortic valve replacement (SAVR) with an Epic Supra valve at our hospital. Survival, incidence of late complications, and echocardiographic date were retrospectively analyzed. During a mean follow-up period of 6.2 ± 3.5years, the overall survival rate was 91 ± 4% at 2 and 88 ± 5% at 5years, while rates of freedom from major adverse cardiovascular and cerebrovascular events (MACCE) were 86 ± 5% and 83 ± 6%, respectively. There was one case of reoperation for prosthetic valve endocarditis at 6years after the initial surgery. Echocardiographic examinations showed 5-year rates of freedom from severe structural valve deterioration (SVD) and moderate SVD of 100 and 92%, respectively. There was no significant increase in mean pressure gradient or decrease in left ventricular ejection fraction from 1week after surgery to the late follow-up period. Long-term clinical results and durability of the Epic Supra valve in aortic position were satisfactory.

Challenges in cardiology: diagnosis of native and prosthetic valve endocarditis.

New cardiovascular imaging technologies have strongly influenced the diagnosis of bacterial endocarditis [infective endocarditis (IE)]. The clinical presentation of IE is polymorphic, which explains the difficulty of diagnosis and the delay in treatment. Symptoms such as fever, chills, loss of appetite and weight, and embolic phenomena strongly support the diagnosis of endocarditis, but are not always present, particularly in elderly or immuno-compromised patients. Moreover, subtle symptoms in patients at high risk for the development of IE, such as those with prosthetic valves or intracardiac devices, patients with congenital heart disease, and drug addicts should lead to the suspicion that a diagnosis of IE is highly probable. In this review, we will focus on the diagnosis of complex IE in native valves and prosthetic valves.

Transcatheter Aortic Valve Replacement for Aortic Valve Infective Endocarditis: A Systematic Review and Call for Action.

We aimed to systematically analyze the literature on the use of transcatheter aortic valve replacement (TAVR) to treat active aortic valve infective endocarditis (AV-IE). Surgery is declined in one-third of patients with IE who meet indications because of prohibitive surgical risk. TAVR might be an alternative for selected patients with AV-IE as a bridge-to-surgery or stand-alone therapy. PubMed/MEDLINE, Embase, and Cochrane databases were searched (2002-2022) for studies on TAVR use in active AV-IE. Of 450 identified reports, six met inclusion criteria (all men, mean age 71 ± 12years, median Society of Thoracic Surgeons (STS) score 27, EuroSCORE 56). All patients were prohibitive surgical risk candidates. Five out of six patients had severe, and one patient had moderate aortic regurgitation on presentation. Five out of six patients had prosthetic valve endocarditis after surgical valve replacement 13years before (median), and one patient had TAVR a year before hospitalization. All patients had cardiogenic shock as the indication for TAVR. Four patients received balloon-expanding, and two patients received self-expanding TAVR after a median of 19(IQR 9-25) days from diagnosis of IE. No death or myocardial infarction occurred, but one patient had a stroke within the first 30days. The median event-free time was 9 (IQR 6-14) months including no death, reinfection, relapse IE, or valve-related rehospitalization. Our review suggests that TAVR can be considered as an adjuvant therapy to medical treatment for selected patients in whom surgery is indicated for treatment of acute heart failure due to aortic valve destruction and incompetence caused by infective endocarditis, but who have a prohibitive surgical risk. Nonetheless, a well-designed prospective registry is urgently needed to investigate the outcomes of TAVR for this off-label indication. No evidence exists for using the TAVR to treat infection-related surgical indications such as uncontrolled infection or control of septic embolization.

18F-FDG-Based Radiomics and Machine Learning: Useful Help for Aortic Prosthetic Valve Infective Endocarditis Diagnosis?

BackgroundFluorine-18 fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET)/computed tomography (CT) results in better sensitivity for prosthetic valve endocarditis (PVE) diagnosis, but visual image analysis results in relatively weak specificity and significant interobserver variability. ObjectivesThe primary objective of this study was to evaluate the performance of a radiomics and machine learning–based analysis of 18F-FDG PET/CT (PET-ML) as a major criterion for the European Society of Cardiology score using machine learning as a major imaging criterion (ESC-ML) in PVE diagnosis. The secondary objective was to assess performance of PET-ML as a standalone examination. MethodsAll 18F-FDG-PET/CT scans performed for suspected aortic PVE at a single center from 2015 to 2021 were retrospectively included. The gold standard was expert consensus after at least 3 months’ follow-up. The machine learning (ML) method consisted of manually segmenting each prosthetic valve, extracting 31 radiomics features from the segmented region, and training a ridge logistic regressor to predict PVE. Training and hyperparameter tuning were done with a cross-validation approach, followed by an evaluation on an independent test database. ResultsA total of 108 patients were included, regardless of myocardial uptake, and were divided into training (n = 68) and test (n = 40) cohorts. Considering the latter, PET-ML findings were positive for 13 of 22 definite PVE cases and 3 of 18 rejected PVE cases (59% sensitivity, 83% specificity), thus leading to an ESC-ML sensitivity of 72% and a specificity of 83%. ConclusionsThe use of ML for analyzing 18F-FDG-PET/CT images in PVE diagnosis was feasible and beneficial, particularly when ML was included in the ESC 2015 criteria. Despite some limitations and the need for future developments, this approach seems promising to optimize the role of 18F-FDG PET/CT in PVE diagnosis.

Management of infectious endocarditis from the perspective of the Infectious Diseases specialist – a 2023 update

An increase in the number and the complexity of cardiac surgery has brought on a rise in the proportion of healthcare-associated Infectious Endocarditis (IE), and as a result, today S. aureus is the most common causative pathogen for this condition. Clinical suspicion for IE should be raised in front of a patient with predisposing risk factors, a new heart murmur and/or vasculitic/embolic events. The Duke Criteria have been long used to diagnose IE. However, they underwent several changes in order to improve their sensitivity in the diagnosis of Q-fever IE and to decrease the size of the possible IE group. Our primary goal is to enhance the knowledge regarding the diagnosis and treatment of infective endocarditis. In acute IE, prior to beginning antibiotic therapy, at least three sets of blood cultures must be taken, ideally from three distinct sites, as determining the etiologic agent is of highest importance. The diagnosis of IE cannot be made based just on a single positive blood culture. To diagnose subacute IE, three to five sets of blood cultures must be drawn over the course of 24 hours. Transthoracic echocardiography (TTE) remains the preferred investigation when the diagnosis of IE is suspected. Transesophageal echocardiography (TOE) is recommended when TTE is unremarkable but the suspicion is still high. A whole-body CT scan, an MRI, a cardiac CT, PET-CT, or radiolabeled leucocyte single-photon emission computed tomography may be helpful when TTE and TOE are inconclusive. Recommended empirical therapy for Native Valve Endocarditis (NVE) and late Prosthetic Valve Endocarditis (PVE) consists of IV Amoxicillin, Oxacillin and Gentamicin administered until blood culture results are available. If a patient is allergic to penicillin, IV Vancomycin and Gentamicin should be given. The recommended empirical antibiotic regimen for early PVE includes IV Vancomycin, Gentamicin, and Rifampin. Once the results of blood cultures are available, the treatment will depend on the isolated organism, its sensitivity to antibiotics, and whether it is an NVE or a PVE.

A Case of Recurrent Infective Endocarditis Caused by Streptococcus Agalactiae.

A 53-year-old man was admitted to hospital with a high fever and shivering. He had undergone aortic valve replacement 4 years previously due to infective endocarditis caused by Streptococcus agalactiae. 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) showed increased uptake in the tissue surrounding the prosthetic valve. S. agalactiae was detected in blood cultures after admission. We made a diagnosis of prosthetic valve endocarditis due to an S. agalactiae infection relapse. After 6 weeks of antibacterial treatment, the inflammatory findings successfully improved. However, reexamination with 18F-FDG PET/CT suggested the possibility of persistent prosthetic valve infection. Therefore, we decided to continue the oral antibiotic treatment after discharge.

Aortic allografts for surgical treatment of prosthetic valve endocarditis

Background: Prosthetic valve endocarditis, the most severe form of infective endocarditis, occurs in 1-6% of patients with valve prostheses and is still associated with poor prognosis and high in-hospital mortality.Objective: To assess outcomes of allograft aortic root replacement in patients with prosthetic valve endocarditis.Methods: The retrospective analysis included adult patients with prosthetic valve endocarditis, who underwent allograft aortic root replacement between 2011 and 2022.Results: Of 15 study patients, early infective endocarditis was found in 60.0% of the cases. The most common cause was Staphylococcus aureus (26.7%). Early mortality was 13.3%. Thromboembolic events occurred in 2 patients (13.3%). The median follow-up period was 48.5 (6-140) months. Late death was reported in 1 patient. The 5-year survival rate was 79.0%. One patient had recurrent infective endocarditis. Two patients underwent reintervention: one for a proximal anastomotic pseudoaneurysm and another one for structural degeneration of the allograft. Five-year freedom from reintervention was 91.7%.Conclusion: Due to the high rate of the freedom from recurrent infective endocarditis, allograft aortic root replacement is an effective treatment for patients with prosthetic valve endocarditis. Received 7 November 2022. Revised 9 December 2022. Accepted 20 December 2022. Funding: The study was supported by the grant of the president of the Russian Federation (No. 075-15-2022-823). Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.V. Bogachev-ProkophievData collection and analysis: A.V. Karadzha, A.N. Pivkin, A.S. ZalesovStatistical analysis: R.M. Sharifulin, A.V. AfanasyevDrafting the article: R.M. Sharifulin, A.V. AfanasyevCritical revision of the article: A.V. Bogachev-Prokophiev, S.I. ZheleznevFinal approval of the version to be published: A.V. Bogachev-Prokophiev, R.M. Sharifulin, S.I. Zheleznev, A.V. Karadzha, A.V. Afanasyev, A.N. Pivkin, A.S. Zalesov

Extensive aortic root endocarditis with extension into the intervalvular fibrous body: an updated report of a mitral valve sparing approach.

Aortic root abscess can spread to include adjacent cardiac structures, including the central or intervalvular fibrous body and mitral valve. After radical debridement, complex surgical correction is needed. We describe the results of our mitral valve sparing approach. Between January 2004 and December 2020, 60 patients underwent operation for infective endocarditis of the aortic root with extension towards the mitral valve at 2 centres in the Netherlands. Early and late clinical and echocardiographic outcomes were studied. Prosthetic valve endocarditis was present in 42 (70%) patients and emergent or salvage surgery was performed in 8 (13%) patients. After radical debridement of all infected tissue, mitral valve repair was feasible in 48 (80%) patients. Early mortality occurred in 11 (18%) patients while mechanical circulatory support was needed in 8 (13%) patients. At 10 years after surgery, the estimated reintervention-free survival rate was 51.9% (95% confidence interval 37.0-66.8%). Eight patients underwent reintervention; this was more common in patients who underwent aortic valve rather than root replacement and in patients in whom mitral valve repair was performed without ring annuloplasty. For 48 patients who underwent mitral valve repair, the estimated freedom from recurrent mitral regurgitation rate was 64.4% (95% confidence interval 40.1-88.7%) at 10 years after surgery. Surgical intervention for extensive infective endocarditis of the aortic root is related to reasonable perioperative morbidity and mortality. Optimal surgical technique is crucial to lower the risk of late reintervention. Mitral valve repair is feasible in the majority of patients with satisfactory durability.

Infective Endocarditis after Transcatheter Aortic Valve Replacement: Challenges in the Diagnosis and Management

Although initially conceived for high-risk patients who are ineligible for surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) is now recommended in a wider spectrum of indications, including among young patients. However, similar to SAVR, TAVR is also associated with a risk of infectious complications, namely, prosthetic valve endocarditis (PVE). As the number of performed TAVR procedures increases, and despite the low incidence of PVE post-TAVR, clinicians should be familiar with its associated risk factors and clinical presentation. Whereas the diagnosis of native valve endocarditis can be achieved straightforwardly by applying the modified Duke criteria, the diagnosis of PVE is more challenging given its atypical symptoms, the lower sensitivity of the criteria involved, and the low diagnostic yield of conventional echocardiography. Delay in proper management can be associated with increased morbidity and mortality. Therefore, clinicians should have a high index of suspicion and initiate proper work-up according to the severity of the illness, the underlying host, and the local epidemiology of the causative organisms. The most common causative pathogens are Gram-positive bacteria such as Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp., and Streptococcus spp. (particularly the viridans group), while less-likely causative pathogens include Gram-negative and fungal pathogens. The high prevalence of antimicrobial resistance complicates the choice of therapy. There remain controversies regarding the optimal management strategies including indications for surgical interventions. Surgical assessment is recommended early in the course of illness and surgical intervention should be considered in selected patients. As in other PVE, the duration of therapy depends on the isolated pathogen, the host, and the clinical response. Since TAVR is a relatively new procedure, the outcome of TAVR-PVE is yet to be fully understood.

Statin use after valvular heart surgery is associated with a decreased risk of prosthetic valve endocarditis

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Sanming Project of Medicine in Shenzhen, China; HKU-SZH Fund for Shenzhen Key Medical Discipline Background Prosthetic valve endocarditis (PVE) is a rare but serious complication following valvular heart surgery for which preventive strategies remain unknown. Recent epidemiological evidence suggests that statins may reduce the risk of infections and infection-related complications. Purpose We aim to assess the association between statin use and the risk of prosthetic valve endocarditis in patients undergoing valvular heart surgery. Methods In all patients undergoing valvular heart surgery in Hong Kong between 2010 and 2021, statin use was ascertained by ≥14-day consecutive filled prescriptions after surgery. Stepwise Poisson regression was applied to identify predictors of PVE. Baseline characteristics between statin nonusers (N = 1400) with statin users (N = 976) were balanced using the inverse probability of treatment weighting. Cox proportional-hazard models with competing risk regression were further performed to estimate the risk of PVE and cardiovascular mortality associated with statin use. Results Our study included 2376 patients; the mean age was 57.8±14.2 years, and 54.4% were males. Over a median follow-up of 5.5 years (interquartile range 2.8-8.6), PVE occurred in 93 patients (6.75 [95% CI 5.51-8.26] PVE events per 1000 person-years). PVE was associated with New York Heart Association Class (Relative Risk [RR] 1.22, 95% Confidence Interval [CI] 1.01-1.45; P = 0.035), prior infective endocarditis (RR 8.64, 95% CI 5.58-13.19; P &amp;lt; 0.001), and aortic valve replacement (RR 1.67, 95% CI 1.11-2.53; P = 0.014). Compared with non-use, statin use was associated with a 47% lower risk of PVE incidence (multivariable-adjusted subdistribution hazard ratio [SHR] 0.53, 95% CI 0.33-0.83; P = 0.006) (Figure 1). This inverse association with the risk of PVE was duration dependent, with an adjusted SHR of 0.60 (95% CI 0.47-0.73; P &amp;lt; 0.001) per year of statin use. Results were consistent across subgroups of sex (male vs female), the number of valvular procedures (single vs multiple), and prosthesis type (mechanical vs biological), but not in groups aged ≤60 years or with prior infective endocarditis (Figure 2). Statin use was associated with a 45% decreased risk of cardiovascular death (SHR 0.55, 95% CI 0.36-0.84; P = 0.006). Conclusions In patients undergoing valvular surgery, post-operative statin use is associated with a lower risk of PVE. These results provide new avenues for preventing PVE and hence valve failure.

Clinical Profile and Predictors of Poor Prognosis in Infective Endocarditis

ABSTRACT Context: Infective endocarditis (IE) is associated with high morbidity and mortality despite advances in diagnosis and treatment. A recent knowledge of the epidemiology and clinical spectrum of IE is essential for prompt recognition and effective therapy. Aims: This study aims to determine the clinical profile, and outcome of patients with IE and to identify the clinical and laboratory predictors of poor prognosis in patients with IE. Settings and Design: This is a prospective observational study among patients diagnosed with IE in a tertiary care center over a period of 12 months. Subjects and Methods: We collected the demographic, clinical, and laboratory evaluation details of consecutive patients admitted with IE. All the patients were followed during hospitalization for mortality, complications, and need for surgery. Statistical Analysis Used: The comparison of mean values across the different outcome groups was done using one-way analysis of variance test. The association between the categorical independent variables with the outcome was evaluated using the Pearson Chi-square test. Results: Among 75 patients admitted with IE rheumatic heart disease was the most common predisposing condition. Blood culture was positive in 80%. Staphylococcus aureus was the most common organism. Total in-hospital mortality was 32%. Staphylococcal IE had 43% mortality and fungal IE had 57% mortality. Prosthetic valve endocarditis also had 57% mortality. Surgery was undertaken in 28% of patients and surgical mortality was 19%. Presence of heart failure, thrombocytopenia, leukocytosis, elevated neutrophil-to-lymphocyte ratio, elevated platelet-to-lymphocyte ratio, high serum creatinine, and C-reactive protein were associated with high mortality. Conclusions: The mortality associated with IE remains high. Clinical and laboratory parameters can reliably predict poor prognosis in IE.

50+ years later, prosthetic valve endocarditis still confounds.

Key Points Prosthetic valve endocarditis is a rare but important complication of transcatheter aortic valve replacement. Treatment of prosthetic valve endocarditis in patients who are status‐post transcatheter aortic valve replacement is difficult due to antibiotic resistance, and outcomes indicate a mortality &gt;10%. In the absence of clinical trials of effective prophylactic antibiotics at the time of transcatheter aortic valve replacement, a careful search for infection both pre‐ and post‐transcatheter aortic valve replacement is critical to prevent infection and treat infection early.

Unfortunate Accidental Twins: Two Patients with Endocarditis of a Valve-Bearing Conduit

Abstract Background Prosthetic valve endocarditis is becoming more common because many patients live long enough to experience bacteremia, while insufficient antibiotic prophylaxis eventually leads to graft infection. Valve-bearing conduit infections are the most feared because of technical challenges. Case Description Two young patients were coincidental twins in terms of diagnosis and therapy. Both underwent complete replacement of the conduit, aortic arch prosthesis, and additional strategies to reconnect the coronary ostia and the brachiocephalic trunk. Both were discharged without significant residual problems. Conclusion Even most demanding infectious problems can be solved. Thus, surgery should not be denied.