Subacute Endocarditis Research Articles

The Usefulness of the CHA2DS2-VASc Score to Predict Outcomes in Patients with Infective Endocarditis.

Introduction: Despite diagnostic and therapeutic advances, infective endocarditis (IE) is still associated with high mortality rates. Currently, there are no good prognostic tools for the risk assessment of patients with IE. The CHA2DS2-VASc score, used to estimate the risk of ischemic stroke in patients with non-valvular atrial fibrillation (AF), has been shown to be a powerful predictor of stroke and death in patients without known AF associated with other cardiovascular conditions. Objective: We aimed to evaluate the usefulness of the CHA2DS2-VASc score as a prognostic tool in a population of patients with IE. Methods: The Rabin Medical Center Endocarditis Team (RMCET) registry is a retrospective cohort of all patients evaluated at our center due to acute or sub-acute bacterial endocarditis. The CHA2DS2-VASc score was extracted for all patients. All-cause mortality was depicted for all patients. Results: The cohort included 330 patients with a mean age of 65.2 ± 14.7 years (70% men). During a median follow-up of 24 months [IQR 4.7-48.6], 121 (36.7%) patients died. The median CHA2DS2-VASc score was 3, and any score above 2 was associated with increased overall mortality (50.8% vs. 19.9%, p < 0.001). A multivariate model incorporating important confounders not included in the CHA2DS2-VASc model showed consistent results with a risk increase of 121% for the higher CHA2DS2-VASc score groups (HR 2.21 [CI 1.12-4.39], p = 0.023). Conclusions: IE currently has no good risk stratification models for clinical practice. The CHA2DS2-VASc score might serve as a simple and available tool to stratify risk among patients with IE.

Aspirin and Ticagrelor Versus Aspirin and Clopidogrel or Prasugrel and the Effect on Staphylococcal-associated Infections: A Real-world Study

Antiplatelet therapy is used for the primary and secondary prevention of thrombotic diseases such as acute coronary syndrome (ACS). These patients are more vulnerable to infections, as such, strategies are required to mitigate these risks. We conducted a retrospective cohort study using TriNetX, a global federated health research network that includes both inpatient and outpatient electronic medical records from health care organizations worldwide. Patients ≥18 years old, after ACS, who were placed on aspirin and ticagrelor were compared with patients placed on aspirin and clopidogrel or prasugrel. Patients were identified using International Statistical Classification of Diseases and Related Health Problems terminology codes. After propensity score matching (1:1), a total of 239,358 patients were identified in each cohort. The primary outcomes of interest investigated were rates of (1) acute and subacute infective endocarditis, (2) sepsis of unknown origin, (3) staphylococcus arthritis, (4) cellulitis and acute lymphangitis, (5) Staphylococcus aureus bacteremia, and (6) staphylococcal pneumonia after initiation of treatment. Outcomes were analyzed at 1, 3, and 5 years. At 5 years, a combination of aspirin and ticagrelor, compared with a combination of aspirin and clopidogrel or prasugrel, was associated with significantly reduced rates of (1) acute and subacute endocarditis (hazard ratio [HR] plus 95% CI) (HR = 0.85; 0.77-0.945; P = 0.030), (2) sepsis of unknown origin (HR = 0.89; 95% CI, 0.86-0.91; P < 0.0001), (3) cellulitis and acute lymphangitis (HR = 0.89; 95% CI, 0.87-0.92; P < 0.0001, and (4) Staphylococcus aureus bacteremia (HR = 0.72; 95% CI, 0.61-0.85; P = 0.0007). However, a combination of aspirin and clopidogrel was associated with a marinally lower risk of staphylococcal pneumonia (HR = 1.04; 95% CI, 1.01-1.062; P < 0.0001). A combination of aspirin and ticagrelor is associated with a lower rate of a variety of bacterial infections. This combination warrants further investigation in in-vitro studies to tease out mechanisms and through clinical randomized trials in groups who have ACS and are at high infection risk.

Computational bioprospecting of phytoconstituents as potential inhibitors for peptide deformylase from Streptococcus oralis: An opportunistic pathogen

Streptococcus oralis an opportunistic bacterium has been reported to be involved in various blood borne infections like subacute bacterial endocarditis, septicemia, bacterial meningitis and in some cases dental caries too. Among various targets the peptide deformylase, of S.oralis appears to be most potent druggable target as it is involved in protein synthesis is opted for the current study. Due to unavailability of PDB structure of peptide deformylase from S. oralis the study initiates with homology modelling of the protein and 6OW2 of S pneumoniae is considered as the template. Thereafter, Molecular docking, Molecular dynamic simulation, ADME analysis, and MMPBSA analysis was carried out to explore the inhibitory potential of phyto-constituents as potential inhibitors for Peptide deformylase from S.oralis. Actinonin was considered as reference drug. Among 2370 phyto compounds the best observations were recorded for A1-Barrigenol (IMPHY010984) with binding affinity of −8.5 kcal/mol. Calculated RMSD, RMSF, Binding Free Energy for IMPHY010984 averaged at about 0.10 ± 0.03 nm, 0.08 ± 0.05 nm, 131 ± 21 kJ/mol respectively whereas the RMSD, RMSF, Binding Free Energy recorded for reference drug averaged at about 0.19 ± 0.04 nm, 0.11 ± 0.08 nm, −94 ± 18 kJ/mol respectively. Based on in silico observations IMPHY010984 is proved out as superior candidate over reference drug. The study reflects the potential of IMPHY010984 as prophylactic therapeutics for S.oralis.

An unusual presentation of subacute Haemophilus parainfluenzae endocarditis in a low-risk woman treated by minimally invasive mitral valve repair: a case report

BackgroundHACEK endocarditis is usually insidious and can often be difficult to diagnose due to the slow-growing nature of the organisms. This report presents our experience in treating a patient with Haemophilus parainfluenzae endocarditis.Case presentationWe describe the case of a previously fit and well 23 year-old woman who presented to her local emergency department with a four-week history of persistent febrile illness. She had associated nausea, vomiting, and lethargy. This was preceded by an episode of mucopurulent rhinorrhoea. She was treated empirically with oral amoxicillin for a putative diagnosis of rhinosinusitis. Initially, her symptoms abated, however, she was readmitted with high fevers and a new pansystolic murmur. Transthoracic echocardiography revealed a large, mobile, echogenic mass, tethered to the posterior mitral valve leaflet (PMVL) and mild mitral regurgitation (MR). On examination, she had multiple non-tender, erythematous macules on the plantar surface of her feet, consistent with Janeway lesions. Two separate blood cultures grew H. parainfluenzae. Infectious diseases recommended a four-week course of intravenous ceftriaxone. Transesophageal echocardiography demonstrated a perforation within the P3 segment of the PMVL. Subsequently, the patient underwent mitral valve repair surgery with an uneventful recovery.ConclusionsOur case highlights the importance of promptly diagnosing HACEK endocarditis. A prolonged course of antibiotic therapy can be lifesaving, and surgery is often necessary to address complications such as perforation within the mitral valve leaflets. In our patient, we were able to perform a sliding P2 leaflet plasty for good quality repair of the mitral valve, through a minimally invasive right anterior thoracotomy.

Repair of a fistula between the aorta and right ventricular outflow tract secondary to infective endocarditis of a unicuspid aortic valve and previously repaired ventricular septal defect

BackgroundInfective endocarditis of the aortic valve can result in a wide range of destructive pathology beyond the valve leaflets and annulus which require careful surgical planning to provide appropriate debridement and reconstruction. Failure to do so can result in a failure of surgical treatment, recurrent infection and cardiac failure with concomitant high morbidity and mortality.Case reportWe describe the case of a 45-year-old male with previous patch repair of a ventricular septal defect, who was diagnosed with sub-acute bacterial endocarditis of the native aortic valve and developed a new fistula from the aorta to the right ventricular outflow tract which. This was managed surgically.ConclusionThis unique case highlights another spectrum of infective endocarditis with a unique approach to repair and management.

Histopathology reveals concealed aortic valve inflammation

BackgroundThe extent of aortic valve inflammation in patients undergoing aortic valve replacement (AVR) is unsettled. The significance of aortic valve histopathology in patients undergoing AVR is undetermined.MethodsA total of 145 resected aortic valves of consecutive patients undergoing surgery for a local aortic valve disease with or without ascending aorta were investigated for histopathology. The extent of inflammation and degeneration were investigated. Unadjusted survival was evaluated by Kaplan–Meier analysis. Median follow-up was 2.7 years (interquartile range 1.5–3.9).ResultsMean patient age was 69 (SD 11) years. Though endocarditis was apparent in only six patients preoperatively, severe aortic valve inflammation was diagnosed histologically in 32 patients of whom 12 patients had acute, subacute or chronic endocarditis. Despite complete aortic valve resection, survival was decreased in patients with severe aortic valve inflammation as opposed to those without (log rank, P = 0.044), even after exclusion of patients with endocarditis, emergency and aortic surgery.ConclusionsAortic valve tissue analysis reveals severe inflammation that may require postoperative treatment. The association of severe but local aortic valve inflammation with patient outcome after aortic valve surgery merits further investigation.

Commentary: Coronary artery mycotic aneurysm in a patient suffering from subacute endocarditis: a case report and literature review

Commentary: Coronary artery mycotic aneurysm in a patient suffering from subacute endocarditis: a case report and literature review

John Alexander Mullin (1835-1899): The Canadian Physician who first described Osler's Nodes.

Sir William Osler (1849-1919), who became Regius Professor of Medicine at Oxford in 1905, first drew attention in 1909 to the painful nodes in subacute bacterial endocarditis, which now carry his eponym, and he published an account in the Quarterly Journal of Medicine, which he helped establish. Attention is drawn to the often overlooked fact that it was a Dr John Alexander Mullin (1835-1899) of Hamilton, Ontario, Canada, who first drew the attention of Sir William Oster to their occurrence. Confusion arose over the relationship between Osler's nodes and the skin lesions described by Theodore Caldwell Janeway (1872-1917), which are generally non-tender and found in acute bacterial endocarditis. The evidence is that there is essentially no difference since their pathogenesis and histological findings are identical.

Клиническое наблюдение пациентки 50 лет с вторичным подострым инфекционным эндокардитом, ассоциированным с имплантированным кардиовертером-дефибриллятором

Клиническое наблюдение пациентки 50 лет с вторичным подострым инфекционным эндокардитом, ассоциированным с имплантированным кардиовертером-дефибриллятором

Analysis of Risk Factors and Intervention Strategies for Acute Kidney Injury After Cardiac Valve Replacement.

To investigate the risk factors and intervention strategies for the development of acute kidney injury (AKI) after cardiac valve replacement with extracorporeal circulation. Retrospective analysis of the clinical data of a total of 106 patients diagnosed with heart valve disease and undergoing extracorporeal circulation heart valve replacement surgery from January 2021 to December 2021 in the Department of Cardiac and Major Vascular Surgery of our hospital. The two groups were divided into AKI and non-AKI groups according to whether acute kidney injury occurred after surgery, and the preoperative, intraoperative and postoperative clinical data were compared. Single-factor analysis and multi-factor logistic regression analysis were used to explore the risk factors for acute kidney injury after extracorporeal heart valve replacement, and to improve the prognosis by giving kidney function protection strategies as early as possible. Univariate analysis showed that age, preoperative blood creatinine >130umol/L, LVEF <45%, presence of subacute infective endocarditis (SIE), concurrent coronary artery bypass grafting (CABG), time to extracorporeal circulation, time to surgery, MAP <70mmHg, urine output <0.5mL/(kg-h), pulmonary infection, low cardiac output, and bacteraemia were risk factors for postoperative AKI. Multi-factor regression analysis showed that preoperative blood creatinine >130umol/l, LVEF <45%, combined infective endocarditis, extracorporeal circulation time >2h, intraoperative and postoperative hypotension, low cardiac output, and postoperative bacteremia were independent risk factors for postoperative AKI. Active intervention strategies in the perioperative period can reduce the occurrence of postoperative AKI and improve patient prognosis.

The Inhibition of Green Okra Fruit (Abelmoschus Esculentus) Extract Against Streptococcus Viridans Root Canals of Teeth

Background: Streptococcus viridans is the most frequently isolated bacterium from infected root canals (63%) and the leading cause of life-threatening sub-acute endocarditis (35%). The use of 2.5% NaOCl as a root canal irrigation material has disadvantages, it is a bad smell and taste, causing allergies, irritating and toxic, so other alternatives are needed. The green okra fruit extract has secondary antibacterial metabolites such as flavonoids, alkaloids, saponins, tannins, and terpenoids. Purpose: This study aims to determine the inhibition of green okra fruit extract against S. viridans. Methods: This research is an experimental laboratory in vitro with a post-test-only control group design. Antibacterial test using the disk diffusion method which consisted of 5 research groups (green okra extract with a concentration of 1,56%, 3,125%, 6,25%, 12,5%, and 2,5% NaOCl) and 4 repetitions. The result was analyzed using non-parametric statistical tests. Results: The average diameter of inhibition zone of each concentration of green okra fruit extract is 1,56% (0 mm ), 3,125% (0 mm), 6,25% (14,58 mm), 12,5% (18,19 mm), and 2,5% NaOCl (23,55 mm). The Kruskal-Wallis test showed a significance value of less than 0.05 which meant that there was a difference in inhibition in all groups. The Mann-Whitney test showed that there were significant differences between the study groups (α&lt;0,05), except for the green okra extract with a concentration of 1,56% with 3,125%. Conclusion: Green okra fruit extract (Abelmoschus esculentus) has inhibition against S. viridans at concentrations of 6,25% (14,58 mm) and 12,5% (18,19 mm) including the strong category.

Simultaneous Live Donor Liver Transplantation, Aortic Valve Replacement, and Atrial Septal Defect Repair in a Patient With End Stage Liver Disease: A Case Report

Valvular heart disease creates an important barrier for orthotopic liver transplantation in patients with end-stage liver disease and increases mortality. Selection of the appropriate surgical scheme and adequate postoperative management can be lifesaving in these cases. This study presents a 32-year-old man diagnosed with hepatitis C-associated cirrhosis and severe aortic regurgitation due to subacute bacterial endocarditis. Initially, simultaneous aortic valve replacement (AVR) and live donor liver transplantation (LDLT) was planned. However, intraoperative transesophageal echocardiography revealed an additional atrial septal defect (ASD) and AVR, ASD repair, and LDLT surgery were performed. During the 2-year follow-up period, there were no early or late complications. To the best of our knowledge, this is the first patient to have simultaneous AVR, ASD repair, and LDLT surgery. Additionally, the present case is also unique in being the first person in the Republic of Azerbaijan to undergo concomitant cardiac surgery and LDLT.

A Patient with Subacute Bacterial Endocarditis and Positive PR3-ANCA: A Case Report and Literature Review

A Patient with Subacute Bacterial Endocarditis and Positive PR3-ANCA: A Case Report and Literature Review

Challenges and prospects of managing non-acute medical conditions among pastoral populations in sub-Saharan Africa.

In Africa, pastoral populations face several underrecognized health issues. The livelihoods of pastoralists revolve around possession of livestock and they are constantly moving in search of water and pasturage. They are predisposed to chronic zoonotic infections but may also suffer from non-acute non-zoonotic cosmopolitan infectious and non-infectious chronic medical conditions. Given their migratory lifestyle, livelihood, geographic inaccessibility, communication barriers, illiteracy and poverty, it is challenging for pastoralists to access lengthy inpatient clinical care and long-term periodic follow-up that may be required to achieve control or cure of subacute, chronic or lifelong diseases. The challenges and management modalities of complicated subacute bacterial endocarditis requiring critical clinical considerations, long-term medical and surgical interventions in a stateless Arab camel herder are described to highlight the plight of pastoralists. Innovative clinical and public health strategies are suggested to authorities and healthcare institutions to improve access to care for non-acute diseases among them.

A patient with subacute bacterial endocarditis and positive PR3-ANCA: A case report and literature review

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Multifaceted Management of Subacute Endocarditis

Multifaceted Management of Subacute Endocarditis

Abstract 14458: It Takes Three to Tango: A Case of Occult Streptococcus Gordonii Infectious Endocarditis After Dental Cleaning Identified by History, Multi-Modal Imaging, and a Multi-Disciplinary Effort

Introduction: We present a case of a 65 year-old man with severe aortic regurgitation requiring a stented 23mm Edwards bioprosthetic aortic valve (BioAVR), who presented with 3-months of fevers and fatigue found to have Streptococcus gordonii ( S. gordonii ) infectious endocarditis (IE). He underwent dental cleaning 3-months prior sans prophylactic antibiotics. An echocardiogram on admission revealed increased peak/mean systolic gradients across the BioAVR to 46/26mmHg compared to gradients one year prior (32/19mmHg). Initially, a vegetation was not visualized by transthoracic echocardiogram (TTE) despite radiographic evidence of multi-organ emboli. Serial TTEs and transesophageal echocardiograms (TEEs) were performed due to persistent symptoms. Eventually, a new vegetation was visualized by TEE. A team effort involving cardiology, infectious disease, neurology, and cardiac surgery was required for management. Revision of the BioAVR was not pursued due to resolution of the vegetation. The patient was discharged after a prolonged hospitalization with recommendations to take amoxicillin 2g prior to future dental work. Results: Figure 1. A new 0.5cm vegetation visualized by TEE (A) with enlargement to 0.8cm (B), followed by a healed vegetation (C), and resolution 7-months later. Conclusions: S. gordonii has historically been a rare cause of IE therefore requiring a high clinical suspicion for diagnosis. Approximately 8% of IE cases are caused by streptococci. However, a recent study in Denmark on streptococci IE implicated S. gordonii in 44.2% of IE cases . S. gordonii is a gram-positive cocci found in oral flora known to cause subacute bacterial endocarditis. Our case highlights the importance of detailed history-taking to identify sources of infection, serial multi-modal imaging evaluation despite initial negative findings particularly with persistent clinical symptoms, and a multidisciplinary approach to IE cases due to multi-organ involvement.

ODP066 Impact of Comorbid Adrenal Insufficiency on Outcomes of Infective Endocarditis Hospitalizations

Abstract Background Adrenocortical integrity is vital to mounting an appropriate response to a potentially deleterious endovascular infection such as infectious endocarditis. Likewise, adrenocortical hormones affect how cytokine storms lead to secondhand injuries that complicate sepsis. Data on the clinical outcomes of infective endocarditis in patients with adrenal insufficiency is limited and thus our attempt to study this topic was perhaps a worthwhile venture. Method: A retrospective cohort study was designed using data obtained from the 2016 to 2018 combined National Inpatient Sample (NIS) database. Adult patients (age &amp;gt;18) admitted with a principal diagnosis of acute and subacute infective endocarditis were identified using the international diseases classification code, tenth revision (ICD-10). They were then stratified into two cohorts based on the presence of adrenal insufficiency. Primary outcomes assessed were, mortality, length of stay (LOS) and total hospital charge. Secondary outcomes included septic shock, embolic stroke, cardiogenic shock, and septic arterial embolization. Multivariate linear and logistic regressions were used to adjust for confounders. Results There was a total of 36,669.97 adult hospitalizations for infective endocarditis, among which 0.67% had a secondary diagnosis of adrenal insufficiency. The presence of adrenal insufficiency led to an increased length of stay (19.66 days vs 13. 05 days, adjusted mean difference of 7.17 days, 95%CI: 1.41 to 12.92 days, p: 0. 015) and an increased total charge (342,312.3 USD vs 147,887.6 USD, adjusted mean difference: 189,447.6 USD, 95%CI: 32,509.7USD to 346,385.5 USD, p: 0. 018) compared with patients without adrenal insufficiency. There was no significant difference in the odds of mortality between the two groups (4. 00% vs 4. 01%, AOR: 0.87, 95% CI: 0.99 to 7.57, p: 0.898). Similarly, other secondary clinical outcomes including septic shock, cardiogenic shock, septic arterial embolization, and embolic strokes were not different between the two cohort groups. Conclusion The presence of adrenal insufficiency among patients admitted with infective endocarditis led to an increased length of stay and a commensurate increased total charge. However, it did not significantly impact the outcomes in terms of mortality, rate of septic shock, cardiogenic shock, septic arterial embolization, or embolic strokes. Presentation: No date and time listed

Granulicatella elegans infective endocarditis: A case report

Granulicatella elegans is a rare cause of infective endocarditis, accounting for 1–2% of all cases. It is well recognized that this pathogen can present in association with negative blood cultures. There are higher rates of both relapse and mortality compared with endocarditis caused by other bacteria. Microbiological diagnosis can be especially challenging because many conventional blood culture media lack pyridoxal, which can be found in automated blood culture broths like BACTEC™ or BACT/ALERT® and thus they may require ‘helper’ bacteria to be culture the organism. This current case report describes a 66-year-old male patient with a 10-year history of post-inflammatory combined aortic valve disease (moderate aortic stenosis and mild aortic regurgitation). He presented with a 3-month history of recurrent fever and general deterioration. Despite targeted, prolonged, combined antibiotic treatment with intravenous penicillin and gentamicin, surgery was eventually required. An aortic prosthetic valve implantation was performed with good results. In case of subacute endocarditis, especially when a causative organism proves difficult to detect, G. elegans should be considered. Identification is greatly enhanced by using polymerase chain reaction methods and this test should be considered in all cases of culture negative endocarditis.

Porphyromonas gingivalis Virulence Factors and Clinical Significance in Periodontal Disease and Coronary Artery Diseases

Porphyromonas gingivalis is a gram-negative, anaerobic bacterium that lives in the oral cavity. It is an integral part of the oral microbiome, which includes more than 500 types of bacteria. Under certain circumstances, as a consequence of virulence factors, it can become very destructive and proliferate to many cells in periodontal lesions. It is one of the causative agents present extremely often in dental plaque and is the main etiological factor in the development of periodontal disease. During various therapeutic procedures, P. gingivalis can enter the blood and disseminate through it to distant organs. This primarily refers to the influence of periodontal agents on the development of subacute endocarditis and can facilitate the development of coronary heart disease, atherosclerosis, and ischemic infarction. The action of P. gingivalis is facilitated by numerous factors of virulence and pathogenicity such as fimbriae, hemolysin, hemagglutinin, capsules, outer membrane vesicles, lipopolysaccharides, and gingipains. A special problem is the possibility of biofilm formation. P. gingivalis in a biofilm is 500 to 1000 times less sensitive to antimicrobial drugs than planktonic cells, which represents a significant problem in the treatment of infections caused by this pathogen.