Risk Of Infective Endocarditis Research Articles

A Review of Dental Imaging and Treatment Protocol Prior to Open Heart Valve Surgery: An Evidence-Based Approach

Context: Open heart valve surgery is associated with a significant risk of infective endocarditis (IE), often linked to oral infections. Despite existing guidelines recommending dental evaluations before surgery, there is no standardized protocol for dental imaging and treatment in this high-risk population. This study aims to present the first evidence-based protocol for dental imaging and treatment to systematically identify and address oral infections, thereby reducing perioperative risks and improving outcomes. Evidence Acquisition: A comprehensive review of current literature on the relationship between oral infections and infective endocarditis was conducted. Existing guidelines from the American Heart Association (AHA) and European Society of Cardiology (ESC) were analyzed. Imaging modalities were integrated into the proposed protocol for preoperative dental evaluation. A risk-based classification system for common dental conditions and antibiotic prophylaxis was developed. Results: The protocol utilizes Imaging techniques to detect oral infections and conditions that could lead to bacteremia, such as dental caries, periodontal disease, and impacted teeth. It also introduces a risk-based approach for managing dental conditions, prioritizing treatments based on urgency, and recommending appropriate antibiotic prophylaxis. This interdisciplinary approach enhances collaboration between dental and cardiac care teams. Conclusions: This study introduces a novel dental imaging and treatment protocol for patients undergoing open heart valve surgery, significantly reducing the risk of infective endocarditis. By addressing oral health systematically before surgery, this protocol improves surgical outcomes and sets a new standard of care for cardiac patients. Future research should validate its effectiveness across diverse healthcare settings and evaluate its long-term impact on patient outcomes.

A Review of the Necessity of Preoperative Dental Evaluations in Nonvalvular Open Heart Surgeries

Context: Preoperative dental evaluations (PDEs) are well-established for valvular cardiac surgeries due to their role in reducing the risk of infective endocarditis (IE). However, their role in nonvalvular open heart surgeries (OHS), such as coronary artery bypass grafting (CABG), remains unclear. Evidence Acquisition: A comprehensive literature review was conducted, analyzing studies that explored the association between oral health and surgical outcomes, the impact of PDEs on postoperative complications, and economic considerations. Results: Preoperative dental evaluations were associated with reduced postoperative infections, shorter ICU stays, and decreased readmission rates in nonvalvular OHS patients. Barriers include lack of guidelines and logistical challenges in emergencies. Conclusions: Incorporating PDEs into preoperative protocols for nonvalvular OHS offers significant clinical and economic benefits, necessitating updated guidelines and interdisciplinary collaboration.

Evaluation of Oral Health Status and Treatment Needs of Children with Congenital and Acquired Heart Disease.

Objective: To evaluate the oral health status and treatment needs of children with congenital and acquired heart disease. Methods: This descriptive study included 301 children aged 5-14 from June 2022 to June 2023. Heart conditions were classified by congenital/acquired status and severity. The children's sociodemographic characteristics, medical and dental history, tooth brushing habits, and non-nutritional habits (bruxism, nail-biting, thumb-sucking, etc.) were evaluated. Oral health assessments including caries, oral hygiene, enamel defects, and dental treatment needs-related indices were recorded. Results: The mean age was 8.95 ± 2.91 years, and 271 (90%) of the children had congenital heart disease. The children with moderate and severe heart disease had significantly higher decayed/missing/filled surfaces (dmfs) (p = 0.038) and pulp exposure (p = 0.015) compared to the children with mild heart disease. According to the International Caries Detection and Assessment System II (ICDAS II) index, which included initial caries lesions, there were no caries-free children and 75.7% had extensive caries. The mean plaque index and gingival index were found to be 1.18 ± 0.38 and 0.69 ± 0.53, respectively. Enamel defects were observed in 15.9%. The Treatment Needs Index (TNI) was 85.8% for the primary teeth and 88.9% for the permanent teeth. The Care Index (CI) was 12.4% for the primary teeth and 10.8% for the permanent teeth. Conclusions: Children with congenital and acquired heart disease exhibit a high prevalence of untreated dental caries, gingivitis, and plaque accumulation, with a high need for dental treatments. Dentists should prioritize addressing these issues to prevent the risk of infective endocarditis (IE) and improve oral health outcomes in this population.

The role of time to positive blood cultures in enhancing the predictive capability of DENOVA score for diagnosing infective endocarditis in patients with Enterococcus faecalis bacteremia.

DENOVA-score is useful to stratify the risk of infective endocarditis (IE) in Enterococcus faecalis bacteremia. Recently, time to positive (TTP) of blood cultures has also been related with a higher risk of IE. The objective was to evaluate DENOVA- score with TTP to improve its specificity. We performed a retrospective, case-control study in adult patients with E. faecalis bacteremia. Thirty-nine patients with definite E. faecalis IE and 82 with E. faecalis bacteremia were included. The addition of a TTP ≤ 8 h to DENOVA-score did not improve the diagnostic accuracy of this score.

Impact of psoriasis on the risk of device-related infective endocarditis in patients with permanent pacemakers: a propensity-matched analysis.

Device-related infective endocarditis (IE) is associated with high mortality, resulting in a growing emphasis on identifying and managing comorbidities that increase the risk of IE in these patients. Psoriasis is increasingly being recognized as having multiple cardiovascular manifestations. However, little is known about the impact of psoriasis on IE risk in patients with permanent pacemakers (PPM). Our study aimed to assess whether psoriasis is associated with an increased risk of developing IE in patients with PPM. The National Inpatient Sample database was utilized to extract patients with PPM. The presence of psoriasis stratified patients. Demographic and comorbidity data were collected. 1:10,000 propensity matching for IE risk factors was performed to examine independent associations between psoriasis and IE. Of 437,793 patients, 45 had psoriasis. Psoriasis patients had higher IE rates (4.4% vs. 0.6%; P < 0.01). On multivariate analysis, psoriasis was associated with a 7.2-fold high IE risk (OR: 7.2 [1.7-30.2]; P < 0.01). Post-match analysis showed an 8.3-fold IE risk in psoriasis patients (OR: 8.3 [2.0-34.4]; P < 0.001). Psoriasis was independently associated with elevated IE risk in patients with PPM. Further studies are required to corroborate these findings, which will have implications for IE prophylaxis.

Incidence and predictive factors of mortality of infective endocarditis in adults with congenital heart disease: A systematic review and meta-analysis

IntroductionCongenital heart diseases (CHD) with abnormal turbulent blood flow are associated with the highest risk of infective endocarditis (IE). Despite advancement in diagnostics and treatment, the mortality rate of IE remains high due the life-threatening complications. Our study aims to assess the incidence and mortality rates of IE and predictive factors for mortality among adults CHD (ACHD). MethodsA systematic literature search was conducted on PubMed, SCOPUS, and Ovid SP to retrieve relevant studies. The pooled estimates and predictors of mortality were calculated using the random-effects generic inverse variance method using R programming. Results12 studies involving 3738 ACHD patients were included in this meta-analysis. The overall incidence of IE in ACHD was 1.26 per 1000 patient-years (95% CI 0.55–1.96). 60% (95% CI 46–72%) of patients had surgical management for IE. The mortality rate of IE was 9% (95% CI 7–12%). The predictors of mortality were conservative management (OR: 5.07, 95% CI: 4.63–5.57), renal dysfunction (OR: 4.15, 95% CI: 2.92–5.88), cerebral complications (OR: 3.59, 95% CI: 1.78–7.23), abscesses/valve complications (OR: 2.67, 95% CI: 1.71–4.16), Staphylococcus aureus infection (OR: 2.32, 95% CI: 1.33–4.06), emboli (OR: 2.03, 95% CI: 1.47–2.79), body mass index (OR: 1.10, 95% CI: 1.01–1.21), age (OR: 1.02, 95% CI: 1.00–1.04), and previous IE (OR: 1.02, 95% CI: 1.00–1.04). ConclusionThe mortality rate of IE in ACHD is low. However, conservative management is associated with the highest risk of mortality.

Automated titanium fastener for surgical aortic valve replacement-preventive role for infective endocarditis?

Evidence on long-term clinical outcomes considering suture-securing techniques used for surgical aortic valve replacement is still uncertain. A total of 1405 patients who underwent surgical aortic valve replacement between January 2016 and December 2022 were included and grouped according to the suture-securing technique used (automated titanium fastener versus hand-tied knots). The occurrence of infective endocarditis during follow-up was set as the primary study end-point. As secondary study end-points, stroke, all-cause mortality, and a composite outcome of either infective endocarditis, stroke, or all-cause mortality were assessed. The automated titanium fastener was used in 829 (59%) patients, whereas the hand-knot tying technique was used in 576 (41%) patients. The multivariable proportional competing risk regression analysis showed a significantly lower risk of infective endocarditis during follow-up in the automated titanium fastener group (adjusted sub-hazard ratio 0.44, 95% confidence interval 0.20-0.94, p = 0.035). The automated titanium fastener group was not associated with an increased risk of mortality or attaining the composite outcome, respectively (adjusted hazard ratio 0.81, 95% confidence interval 0.60-1.09, p = 0.169), (adjusted hazard ratio 0.82, 95% confidence interval 0.63-1.07, p = 0.152). This group was not associated with an increased risk of stroke (adjusted sub-hazard ratio 0.82, 95% confidence interval 0.47-1.45, p = 0.504). Also, a significantly lower rate of early-onset infective endocarditis was observed in the automated titanium fastener group, (0.4% vs 1.4%, p = 0.032). Suture-securing with an automated titanium fastener device appears to be superior compared to the hand-knot tying technique in terms of lower risk of infective endocarditis.

Comparison of infective endocarditis in patients with and without malignancy: A propensity score matched analysis.

e24030 Background: Cancer patients are at a higher risk of infective endocarditis (IE) due to immunosuppressed state, indwelling catheters and recurrent infections. Due to the clinical scenario being relatively uncommon, there is lack of real-world data on prevalence, trends and outcomes of IE in cancer patients. Methods: We extracted data from the National Inpatient Sample (NIS) Database from 2016 to 2020. We included all admissions ≥18 years old with a principal diagnosis of IE with and without a cancer diagnosis using International Classification of Diseases Tenth Revision (ICD-10) codes. Propensity score matching was performed to balance hospital characteristics, patient demographics and comorbidities between the two groups. Univariate logistic regression was performed in the balanced cohorts. The primary outcome was inpatient mortality. Analysis was performed using STATA-MP, version 14.2. Results: A total of 70,225 admissions for IE were identified between 2016-2020, of which 2,294 (3.27%) had a history or active cancer. The annual number of admissions for IE did not show a significant change (p trend = 0.56); however, the proportion of IE patients with cancer doubled from 2.33% to 4.61% (p trend &lt; 0.01) over the study period. After propensity score matching, there was no significant difference in in-hospital mortality (odds ratio [OR] 1.30, 95% CI 0.79-2.16, p = 0.31) between IE patients with and without cancer. Cohort with cancer had lower odds of experiencing respiratory failure (OR 0.52, 95% CI 0.33-0.83, p &lt; 0.01) and stroke (OR 0.35, 95% CI 0.25-0.49, p &lt; 0.01), although venous thromboembolism was more common in cohort with cancer (OR 3.03, 95% CI 1.76-5.21, p &lt; 0.01). There was no difference in acute kidney injury or shock between the two groups. Cohort with cancer was less likely to undergo valve replacement surgery (OR 0.42, 95% CI 0.31-1.24, p &lt; 0.01). The median length of stay (11 days vs 14 days, p &lt; 0.01) and hospital charges ($70,698 vs $86,763, p &lt; 0.01) were higher in the cohort without cancer. Conclusions: Underlying cancer was seen in growing proportion of admissions for IE over the study period. The pattern of complications was different between patients with and without cancer, which underscores the importance of cancer history in management of IE. Although there was no difference in mortality between patients with and without cancer, patients with cancer were less likely to undergo valve replacement surgery during the admission. Further research is needed to explore the specific factors influencing treatment decisions and long-term outcomes in cancer patients with IE.

#3043 Epidemiology of infective endocarditis in long term hemodialysis patients in France, from 2014 to 2019

Abstract Background and Aims Infective endocarditis (IE) is a frequent pathology among patients treated with long-term hemodialysis (HD). Its epidemiology and risk factors are scarcely reported in this specific population in France. This study aims to describe the frequency and characteristics of IE in long-term hemodialysis patients in mainland France. Method From the national Programme de médicalisation des systèmes d'information (PMSI) data, we selected patients initiating a renal replacement therapy by long-term hemodialysis from 2014 to 2017, with a follow up from 2017 to 2019. Within this population, we defined hospitalizations due to IE by using the CIM-10 coding system. We analyzed various comorbidities such as sociodemographic factors, cardiovascular diseases, cancer, diabetes and vascular access, identified within the PMSI during a minimum duration of 4 years, looking for IE risk factors. As the IE incidence has a low frequency for this follow up length, it was analyzed with a Poisson distribution model. Results We studied 38 569 patients, with a 36 month follow up. Fig. 1 shows IE incidence during the follow up, in which we identified 2492 cases of EI. The incidence rate was 6.69, or 7 out of 100 000 at first month and 1.97 out of 100 000 at twelve months. In multivariate analysis we found the following risk factors associated with EI: having a central vascular catheter (CVC) as initial vascular access while starting renal replacement therapy, compared to an arteriovenous fistula, OR 2.49 [2.29-2.71], diabetes OR 1.25 [1.14-1.35], cardiovascular conditions OR 1.35 [1.23-1.48] and increasing age was associated with a reduction of an IE diagnosis odds. Conclusion Our study highlights a high IE frequency among long-term hemodialysis patients. Its incidence is particularly high during the first year and decreases afterwards. The main risk factors were: CVC, preexisting cardiovascular conditions and diabetes.

Risk of infective endocarditis and complicated infection in Staphylococcus aureus bacteremia – a retrospective cohort study on the role of bacteriuria

PurposeS. aureus bacteremia (SAB) is a common and severe infection with high mortality and morbidity. The clinical relevance of the finding of concurrent S. aureus bacteriuria (SABU) is debated. The goal of this study was to analyze whether a concurrent SABU is associated with complicated SAB, infective endocarditis (IE) and mortality.MethodsWe conducted a retrospective cohort study, reviewing medical charts of all episodes of SAB in patients > 18 years in the region of Skåne, Sweden, between 1st of January and 31st of June 2020. Episodes where a concurrent urine culture was performed were included for analysis. An episode was considered as complicated SAB if there was either attributable mortality, recurrent infection, embolic stroke, or occurrence of a complicated focus of infection.ResultsDuring the study period, there were 279 episodes of SAB. 154 episodes met the eligibility criteria, of whom 37 (24%) had concurrent SABU. In 78 episodes (51%), the patients had a complicated SAB. There was a significantly lower proportion of complicated SAB for episodes with concurrent SABU (32%), compared to episodes without concurrent SABU (56%), p-value 0.014. Moreover, in the cohort there were 11 episodes (7.1%) of IE and a 30 days mortality rate of 16%, with no difference between the groups with or without SABU.ConclusionsThere is an association between concurrent SABU and a decreased risk for complicated SAB among patients with SAB. This study found no significant association between SABU and neither IE nor mortality for patients with SAB.

Infective endocarditis is rare in patients with hematologic malignancy and neutropenia.

Infective endocarditis (IE) is a serious complication of bloodstream infections (BSIs) that occurs at variable rates depending on the pathogen and clinical setting. There is a paucity of data describing the risk of IE in patients with hematologic malignancy who develop bacteremia while neutropenic. Adult patients on the hematology ward from January 2018 to December 2020 with hematologic malignancy and bacteremia were evaluated retrospectively for endocarditis by applying the 2023 Duke-ISCVID criteria. Charts of possible cases were evaluated 90 days after the initial BSI for new infectious complications that could indicate missed IE. Descriptive statistics compared patients admitted for hematopoietic stem cell transplantation (HSCT) to those admitted for alternative reasons (non-HSCT). Among the 1005 positive blood cultures initially identified, there were 66 episodes in 65 patients with hematologic malignancy and at least grade 3 neutropenia for a mean duration of 11.4 days during their admission. Transthoracic echocardiography (TTE) was performed in 34.8% of BSIs, and transesophageal echocardiography (TEE) in 6.1%. There were no new infectious complications in possible cases 90 days after their initial BSI. No cases of endocarditis were identified. Endocarditis is rare amongst patients with hematologic malignancy, bacteremia, and neutropenia, and no cases were identified in this cohort. The use of routine TTE in this setting seems unwarranted, and the addition of TEE is unlikely to improve patient-centered outcomes.

Performance of Risk Scores in Predicting Infective Endocarditis in Patients with Staphylococcus aureus Bacteraemia in a Prospective Asian Cohort.

Background: Several risk scores have been derived to predict the risk of infective endocarditis (IE) amongst patients with Staphylococcus aureus bacteraemia (SAB), which helps to guide clinical management. Methods: We prospectively studied 634 patients admitted with SAB. The cohort was stratified into those with or without IE, and the PREDICT Day 1, Day 5 and VIRSTA scores were tabulated. Area under the receiver operating characteristic (AUC) curves were constructed to compare the performance of each score. Results: Of the 634 patients examined, 36 (5.7%) had IE. These patients were younger (51.6 ± 20.1 vs. 59.2 ± 18.0 years, p = 0.015), tended to have community acquisition of bacteraemia (41.7% vs. 17.9%, p < 0.001), and had persistent bacteraemia beyond 72 h (19.4% vs. 6.0%, p = 0.002). The VIRSTA score had the best performance in predicting IE (AUC 0.76, 95%CI 0.66-0.86) compared with PREDICT Day 1 and Day 5. A VIRSTA score of <3 had the best negative predictive value (97.5%), compared with PREDICT Day 1 (<4) and Day 5 (<2) (94.3% and 96.6%, respectively). Conclusions: Overall, the risk scores performed well in our Asian cohort. If applied, 23.5% of the cohort with a VIRSTA ≥ 3 would require TEE, and a score of <3 had an excellent negative predictive value.

Prevention of infective endocarditis in at-risk patients: how should dentists proceed in 2024?

National Institute for Health and Care Excellence (NICE) guidelines are ambiguous over the need for patients at increased risk of infective endocarditis (IE) to receive antibiotic prophylaxis (AP) prior to invasive dental procedures (IDPs), and this has caused confusion for patients and dentists alike. Moreover, the current law on consent requires clinicians to ensure that patients are made aware of any material risk they might be exposed to by any proposed dental treatment and what can be done to ameliorate this risk, so that the patient can decide for themselves how they wish to proceed. The aim of this article is to provide dentists with the latest information on the IE-risk posed by IDPs to different patient populations (the general population and those defined as being at moderate or high risk of IE), and data on the effectiveness of AP in reducing the IE risk in these populations. This provides the information dentists need to facilitate the informed consent discussions they are legally required to have with patients at increased risk of IE about the risks posed by IDPs and how this can be minimised. The article also provides practical information and advice for dentists on how to manage patients at increased IE risk who present for dental treatment.

New evidence calls into question NICE's endocarditis prevention guidance

In 2008, National Institute for Health and Care Excellence (NICE) guidelines recommended against the use of antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to prevent infective endocarditis (IE). They did so because of lack of AP efficacy evidence and adverse reaction concerns. Consequently, NICE concluded AP was not cost-effective and should not be recommended. In 2015, NICE reviewed its guidance and continued to recommend against AP. However, it subsequently changed its wording to ‘antibiotic prophylaxis against infective endocarditis is not routinely recommended'. The lack of explanation of what constituted routinely (and not routinely), or how to manage non-routine patients, caused enormous confusion and NICE remained out of step with all major international guideline committees who continued to recommend AP for those at high risk.Since the 2015 guideline review, new data have confirmed an association between IDPs and subsequent IE and demonstrated AP efficacy in reducing IE risk following IDPs in high-risk patients. New evidence also shows that in high-risk patients, the IE risk following IDPs substantially exceeds any adverse reaction risk, and that AP is therefore highly cost-effective. Given the new evidence, a NICE guideline review would seem appropriate so that UK high-risk patients can receive the same protection afforded high-risk patients in the rest of the world.

Occurrence and Outcome of Infective Endocarditis after Surgical Compared to Transcatheter Pulmonary Valve Implantation in Congenital Heart Disease.

Background: Conflicting data exist on the occurrence and outcome of infective endocarditis (IE) after pulmonary valve implantation. Objectives: This study sought to assess the differences between transcatheter pulmonary valve implantation (TPVI) and surgical pulmonary valve replacement (SPVR). Methods: All patients ≥ 4 years who underwent isolated pulmonary valve replacement between 2005 and 2018 were analyzed based on the data of a major German health insurer (≈9.2 million insured subjects representative of the German population). The primary endpoint was a composite of IE occurrence and all-cause death. Results: Of 461 interventions (cases) in 413 patients (58.4% male, median age 18.9 years [IQR 12.3-33.4]), 34.4% underwent TPVI and 65.5% SPVR. IE was diagnosed in 8.0% of cases during a median follow-up of 3.5 years. Risk for IE and all-cause death was increased in patients with prior IE (p < 0.001), but not associated with age (p = 0.50), sex (p = 0.67) or complexity of disease (p = 0.59). While there was no difference in events over the entire observational time period (p = 0.22), the time dynamics varied between TPVI and SPVR: Within the first year, the risk for IE and all-cause death was lower after TPVI (Hazard Ratio (HR) 95% CI 0.19 (0.06-0.63; p = 0.006) but increased over time and exceeded that of SPVR in the long term (HR 10.07 (95% CI 3.41-29.76; p < 0.001). Conclusions: Patients with TPVI appear to be at lower risk for early but higher risk for late IE, resulting in no significant difference in the overall event rate compared to SPVR. The results highlight the importance of long-term specialized care and preventive measures after both interventions.

Make Modern Microbiology Matter More in the 2023 European Society of Cardiology Guidelines for the Management of Infective Endocarditis.

The European Society of Cardiology (ESC) 2023 guidelines for the management of infective endocarditis (IE) stress that a multidisciplinary approach is needed to manage patients with IE. In our view, the guidelines do not include the relevant perspectives from modern microbiology. The diagnostic criteria for IE were changed in the ESC 2023 guidelines, and many IE-causing pathogens are either not clearly defined. Moreover, an improved understanding of the relationship between bacterial species and the risk for IE has not been implemented. The guidelines give detailed and, in our view, incorrect instructions about diagnostic testing in blood culture-negative IE without presenting proper evidence. Other important diagnostic aspects, such as the value of repeated blood cultures and incubation time for blood cultures, are not discussed. We believe that a multidisciplinary collaboration that include microbiologists would have improved these guidelines, and we hope for a future harmonization of diagnostic criteria for IE.

Non-betahemolytic streptococcal bacteremia, cardiac implantable electronic device, endocarditis, extraction, and outcome; a population-based retrospective cohort study.

Patients with non-beta-hemolytic streptococcal bacteremia (NBHSB) are at risk of infective endocarditis (IE). Patients with cardiac implantable electronic device (CIED) have been described to have an increased risk of IE. The aim of the study was to describe a population-based cohort of patients with NBHSB and CIED and variables associated with IE and recurrent NBHSB. All episodes with NBHSB in blood culture from 2015 to 2018 in a population of 1.3 million inhabitants were collected from the Clinical Microbiology Laboratory, Lund, Sweden. Through medical records, patients with CIED during NBHSB were identified and clinical data were collected. Patients were followed 365days after NBHSB. Eighty-five episodes in 79 patients with CIED and NBHSB constituted the cohort. Eight patients (10%) were diagnosed with definite IE during the first episode, five of whom also had heart valve prosthesis (HVP). In 39 patients (49%) transesophageal echocardiography (TEE) was performed of which six indicated IE. Four patients had the CIED extracted. Twenty-four patients did not survive (30%) the study period. Four patients had a recurrent infection with NBHSB with the same species, three of whom had HVP and had been evaluated with TEE with a negative result during the first episode and diagnosed with IE during the recurrency. The study did not find a high risk of IE in patients with NBHSB and CIED. Most cases of IE were in conjunction with a simultaneous HVP. A management algorithm is suggested.

Antibiotic Prophylaxis and Infective Endocarditis Incidence Following Invasive Dental Procedures

The association between antibiotic prophylaxis and infective endocarditis after invasive dental procedures is still unclear. Indications for antibiotic prophylaxis were restricted by guidelines beginning in 2007. To systematically review and analyze existing evidence on the association between antibiotic prophylaxis and infective endocarditis following invasive dental procedures. PubMed, Cochrane-CENTRAL, Scopus, Web of Science, Proquest, Embase, Dentistry and Oral Sciences Source, and ClinicalTrials.gov were systematically searched from inception to May 2023. Studies on the association between antibiotic prophylaxis and infective endocarditis following invasive dental procedures or time-trend analyses of infective endocarditis incidence before and after current antibiotic prophylaxis guidelines were included. Study quality was evaluated using structured tools. Data were extracted by independent observers. A pooled relative risk (RR) of developing infective endocarditis following invasive dental procedures in individuals who were receiving antibiotic prophylaxis vs those who were not was computed by random-effects meta-analysis. The outcome of interest was the incidence of infective endocarditis following invasive dental procedures in relation to antibiotic prophylaxis. Of 11 217 records identified, 30 were included (1 152 345 infective endocarditis cases). Of them, 8 (including 12 substudies) were either case-control/crossover or cohort studies or self-controlled case series, while 22 were time-trend studies; all were of good quality. Eight of the 12 substudies with case-control/crossover, cohort, or self-controlled case series designs performed a formal statistical analysis; 5 supported a protective role of antibiotic prophylaxis, especially among individuals at high risk, while 3 did not. By meta-analysis, antibiotic prophylaxis was associated with a significantly lower risk of infective endocarditis after invasive dental procedures in individuals at high risk (pooled RR, 0.41; 95% CI, 0.29-0.57; P for heterogeneity = .51; I2, 0%). Nineteen of the 22 time-trend studies performed a formal pre-post statistical analysis; 9 found no significant changes in infective endocarditis incidence, 7 demonstrated a significant increase for the overall population or subpopulations (individuals at high and moderate risk, streptococcus-infective endocarditis, and viridans group streptococci-infective endocarditis), whereas 3 found a significant decrease for the overall population and among oral streptococcus-infective endocarditis. While results from time-trend studies were inconsistent, data from case-control/crossover, cohort, and self-controlled case series studies showed that use of antibiotic prophylaxis is associated with reduced risk of infective endocarditis following invasive dental procedures in individuals at high risk, while no association was proven for those at low/unknown risk, thereby supporting current American Heart Association and European Society of Cardiology recommendations. Currently, there is insufficient data to support any benefit of antibiotic prophylaxis in individuals at moderate risk.

Heart failure — An unexplored risk factor for infective endocarditis after pacemaker implantation

BackgroundWith the widespread use of permanent pacemakers (PPM), and increased mortality associated with pacemaker endocarditis, it is essential to evaluate comorbidities that could potentially increase the risk of infective endocarditis (IE). Heart failure (HF), a common comorbidity, has not been well studied as an independent risk factor for development of IE in individuals with PPM. MethodsThe US National Inpatient Sample database was used to sample individuals with PPM. Patients with concomitant implantable cardioverter defibrillator, acute heart failure, history of endocarditis, intravenous drug use, prosthetic heart valves, or central venous catheter infection were excluded. Propensity matching was performed to match patients with and without HF. Pre- and post-match logistic regression was performed to assess HF as an independent risk factor for IE. A subgroup analysis was performed comparing IE rates between patients with HF with reduced (HFrEF) vs preserved (HFpEF) ejection fraction. ResultsOut of 333,571 patients with PPM included in the study, 121,862 (37 %) had HF. HF patients were older and had a higher prevalence of females. All comorbidities except for dental disease and cancer were more prevalent in the HF group. Patients with HF were 1.30 times more likely to develop IE [OR: 1.30 (1.16–1.47); p < 0.001]. The two cohorts were then matched for age, gender, and 20 comorbidities using a 1:1 propensity score matching algorithm. After matching, HF was still independently associated with increased risk of IE [OR: 1.62 (1.36–1.93); p < 0.001]. In our sub-group analysis, HFrEF and HFpEF patients had similar IE rates. ConclusionIn PPM population, HF was associated with an increased risk of IE compared to those without HF. We hypothesize that HF being a low-flow and high-inflammatory state might have contributed to this increased risk. Larger studies are required to corroborate our findings and evaluate the need for antimicrobial prophylaxis for this population.

Risk of infective endocarditis after hybrid melody mitral valve replacement in infants: the French experience.

Surgical management of mitral valve disease is challenging in infants <1 year old. We aimed at reviewing the French experience with Melody mitral valve replacement in critically ill infants. A retrospective cohort study reporting the French experience with Melody mitral valve replacement. Seven symptomatic infants [complete atrioventricular septal defect (n = 4, Down syndrome: n = 3), hammock valve (n = 3)] underwent Melody mitral valve replacement [age: 3 months (28 days to 8 months), weight: 4.3 kg (3.2-6.4 kg)] because of severe mitral valve regurgitation (6) or mixed valve disease (1) and 14 mm (11-16 mm) mitral valve annulus. In 2 patients whose valve was felt irreparable, Melody mitral valve replacement was performed straightaway. The others underwent 2 (1-3) previous attempts of valve repair; 3 were on extracorporeal membrane oxygenation. Melody mitral valve replacement led to competent valve and low gradient [3 mmHg, (1-4 mmHg)]. One patient died 3 days post-implant from extracorporeal membrane oxygenation-related stroke. Of the 6 discharged home patients, 3 (50%) were readmitted for a definite diagnosis (1) or high suspicion (2) of infective endocarditis, of which 2 died. Over the follow-up, 1 underwent balloon expansions of the valve at 9- and 16-months post-implant, and mechanical mitral valve replacement at 2 years; another is currently planned for transcatheter Melody valve dilation. Melody mitral valve replacement may be considered in selected infants with small mitral valve annulus as an alternative to mechanical mitral valve replacement. Our experience highlights a high-risk of late infective endocarditis that deserves further consideration.