Surgical Intervention For Infective Endocarditis Research Articles

(161) Induction With Microdoses of Buprenorphine Perioperatively in Opioid Use Disorder Patients Undergoing Surgical Intervention for Infective Endocarditis

(161) Induction With Microdoses of Buprenorphine Perioperatively in Opioid Use Disorder Patients Undergoing Surgical Intervention for Infective Endocarditis

Epidemiology and Characteristics of Surgical Intervention for Infective Endocarditis: A Population-Based Study in the Past Two Decades (2000 – 2019) in Hong Kong

Background The ‘inflamm-ageing’ phenomenon may worsen the prognosis of heart diseases including infective endocarditis (IE), while surgery may reduce inflammatory burden by direct removal of bacterial vegetation. This study aims to characterize the epidemiological and clinical features of surgical intervention for IE in Hong Kong in the past two decades. Methods All patients with incident IE from 2000-2019 in a territory-wide database were identified. We studied the trends in age-specific incidence of IE and identified the most significant contributors to 1-year all-cause death using the population attributable fraction (PAF). A propensity score approach was used to evaluate the benefits of surgical intervention. Results A total of 5,657 patients (mean age 60 years, 37% women) were included. Patients have become older, with an increasing trend in mean age from 2000-2019 (annual percentage change [APC] 0.9%, 95% CI 0.8 to 1.1, P Conclusions Patients with IE have become older in the past two decades, while surgical intervention significantly improved survival. Our results may help to improve outcomes of patients with IE by informing public health and clinical decisions.

Heart failure presentation thirty years after tricuspid valvectomy for infective endocarditis

Heart failure presentation thirty years after tricuspid valvectomy for infective endocarditis

Abstract 11890: Timing of Surgery for Infective Endocarditis: A Network Meta-Analysis

Introduction: Infective endocarditis (IE) is associated with in-hospital mortality of 15-30%. Surgery is recommended in approximately 50%. The best available evidence from meta-analyses has demonstrated benefit of early surgical intervention (SI) for the management of IE. However, the timing of surgery has not been further sub-stratified and internally compared Methods: We performed a frequentist network meta-analysis adhering to PRISMA Guidelines. Observational studies comparing SI for infective endocarditis at different time points - SI performed <48 hours of diagnosis, 2-7 days, 7-14 days, 14-28 days, 28+ days - were included for analysis. In-hospital mortality, all-cause mortality, in-hospital embolic events, and recurrence of endocarditis were used as outcome variables. All analysis was performed on R, using the open-source net meta-package. Results: A total of 28 studies met our inclusion criteria. Figure 1A shows forest plots for each outcome. SI at any time period improved all-cause mortality. However, only Surgery > 21 days resulted in improved in-hospital mortality (OR = 0.19 (0.04-0.85)). Intervention at any specific surgical window did not improve in-hospital embolic events or recurrence of endocarditis. Figure 1B shows SUCRA-dependent hierarchical ranking. Surgery greater than 21 days (S = 0.9443), followed by Surgery < 48 hours (S = 0.7133) was superior to other intervention windows. Surgery < 48 hours also was found to have a higher rank for in-hospital embolic events (S = 0.947). Conclusions: Our results supplement the existing society consensus statements and guidelines to opt for early SI, by positing the value of SI within 48 hours. If the patient is stable SI can be performed after 21 days for better in hospital mortality rates. Randomized control trials need to be performed to evaluate further.

Survival benefits and optimal timing for surgical intervention for infective endocarditis

Abstract Background Surgery is often indicated in patients with infective endocarditis (IE), but the survival benefits of surgical intervention have not been validated in large-scale studies. Although previous studies appeared to support early surgical intervention, the optimal timing of intervention remains uncertain. Purpose We aim to evaluate the benefits of surgery and identify the optimal timing of surgical intervention for patients with IE. Methods From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. Patients were divided into those who received surgical intervention within 1 year of IE (surgical cohort) and those who did not (control cohort). The two cohorts were then compared using inverse probability weighting of the covariate balancing propensity score, which included demographics, comorbidities, and causative organism as covariates. Outcomes of interest include, at 1 year, all-cause death, and the development of complications. A Cox proportional hazards model was used to evaluate the association between surgical intervention and death, with “doubly-robust estimation” used to minimise the effect of confounders. For complications, a Fine-Gray model was used to account for competing risk. The surgical cohort was subdivided into early (≤7 days of hospitalisation) or late surgical intervention; a similar propensity score analytic approach was used to evaluate the effects of early vs. late intervention, with those who died within the 7 days excluded to ensure a fair comparison. Results A total of 5,657 patients (age 59.9±18.3 years, 37.2% females) were included, of which 930 (16.4%) received surgical intervention in 1 year. Overall, the surgical cohort had a 45% risk reduction in all-cause death (hazard ratio [HR] 0.55, 95% CI [0.46 to 0.65], P<0.001) (Figure). This association remained consistent in subgroup analysis stratified by age, sex, and causative organisms (Table 1). The surgical cohort also had a lower risk of complications, including acute kidney injury (HR 0.61, 95% CI 0.43 to 0.87, P=0.006), systemic embolism (HR 0.35 [0.23 to 0.55], P<0.001), ischaemic stroke (HR 0.37 [0.24 to 0.55], P<0.001), cardiac dysrhythmia (HR 0.79 [0.66 to 0.95], P=0.011), and pneumonia (HR 0.36 [0.26 to 0.49], P<0.001). In the surgical cohort, compared to those who had early surgery (N=181), those with delayed surgery had a lower risk of all-cause death (HR 0.58 [0.34 to 0.99], P=0.045) (Figure) and complications (Table 2) at 1 year. In those who had early surgery, patients who received ultra-early surgery (≤3 days of hospitalisation, N=104) did not have a significantly different risk of death (HR 1.19 [0.47 to 3.34], P=0.654). Conclusions Surgical intervention significantly reduced the risk of death and complications in patients with infective endocarditis. Delayed surgical intervention appeared to be more protective. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Epidemiology of infective endocarditis in Hong Kong, 2000–2019

Abstract Background/Introduction Despite improvements in diagnostic and therapeutic strategies, the mortality and morbidity of infective endocarditis (IE) remain high. The incidence, outcomes, and surgical intervention of IE, particularly in an Asian population, are poorly understood and characterised, and the effect of antibiotic prophylaxis guidelines revision on the incidence of IE remains unexplored. Purpose We aim to describe temporal changes in the epidemiology and surgical intervention for IE in Hong Kong in the past 2 decades. Methods From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. The temporal trends in the incidence of IE, rate of surgical intervention, and mean Charlson Comorbidity Index (CCI) were characterised using Poisson regression analysis and expressed in annual percentage change (APC [95% CI]). Interrupted time series analysis was used to evaluate the change in incidence after the revision of antibiotic prophylaxis guidelines. The association between surgical intervention and mortality was evaluated using propensity score analytics. Temporal trends in 1-year all-cause mortality were evaluated using multivariable Cox regression. Results A total of 5,657 patients (59.9±18.3 years, 37.2% females) were included. The crude incidence remained was stable from 2000 to 2019 (APC 0.1% [−0.5 to 0.7], P=0.675), and remained unchanged following the revision of antibiotic prophylaxis guidelines in 2008 (relative risk of change 0.90 [0.64 to 1.00], P=0.065) (Figure 1). Concordant with an increase in the mean age of IE patients (APC 0.9% [0.8 to 1.1], P<0.001), the comorbidity burden grew substantially from 2000 (CCI 0.55±1.27) to 2019 (CCI 1.09±1.66). The rate of surgical intervention significantly increased from 5.3% in 2000 to 17.8% in 2019 (APC 2.7% [1.1 to 4.3], P=0.004), and surgical intervention at 1 year was associated with a 45% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.55 [0.46 to 0.65], P<0.001). Nevertheless, the crude all-cause mortality rate at 1 year increased from 27.4% in 2000 to 31.5% in 2019, with no significant trend after adjustment for demographics and comorbidities (APC −0.7% [−1.6 to 0.1], P=0.087). Conclusions In this large cohort of Asian patients, the incidence of IE remained static and did not change following the revision of antibiotic prophylaxis guidelines. Over time, patients with IE have evolved to be older and more comorbid. Despite an increasing rate of surgical intervention that conferred improved survival, the mortality of IE remained irresistibly high. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Sex differences in health resource utilization, costs and mortality during hospitalization for infective endocarditis in the United States

BackgroundFew studies have assessed the association between sex and outcomes among patients with infective endocarditis. The aim of the study was to better understand the association between biologic sex, clinical outcomes and surgical treatment patterns among a contemporary cohort of patients admitted to hospital with infective endocarditis. MethodsWe used the National Inpatient Sample dataset from the Health Care Utilization Project to identify adult patients admitted for infective endocarditis between January and December 2016. We compared outcomes between men and women including inpatient hospital mortality, direct hospital costs, length of stay, and inpatient surgical treatment patterns. Multivariable analyses were performed with adjustment for age, socioeconomic status, and comorbidity burden. ResultsAmong 18,702 patients with infective endocarditis, there were 8730 (46.7%) women and 1753 (8.4%) in-hospital deaths. In multivariable analysis, female sex was associated with a trend toward lower in-hospital mortality (adjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.80 to 1.01, p = 0.06). Additionally, female sex was associated with significantly shorter hospital length of stay (−0.5 days; 95% CI −0.88 to −0.12, p = 0.009) and lower hospital costs (−$3035; 95% CI −$4277 to −$1792; p < 0.001). Notably, women were less likely to undergo surgical intervention (adjusted OR 0.59; 95% CI 0.52 to 0.67, p < 0.001). ConclusionsIn a contemporary, nationally representative cohort of patients admitted for IE in the United States, there were sex-specific differences in management and in-hospital outcomes. Possible sex-based bias in treatment patterns and access to inpatient surgical intervention for infective endocarditis warrants further study.

Association between surgical treatment and in-hospital mortality in patients with infective endocarditis stratified by NYHA classification: a nationwide retrospective study in Japan

Abstract Background Heart failure (HF) is one of the major complications of infective endocarditis (IE). The ESC guideline described that surgical treatment should be performed for the patients with IE complicated with HF. However, decision making of surgical indication in real-world clinical setting is not easy for patients with IE concomitant with HF due to complicated conditions, and the clinical benefit of surgical intervention for IE and HF is unclear. Purpose We sought to uncover the association between surgical treatment and in-hospital mortality among the patients admitted for community-acquired IE respectively according to the severity of HF symptoms (NYHA class I to IV). Methods We studied 3,403 patients diagnosed as IE (mean age 65.9 years, 61.6% males) with records of baseline NYHA classification (I to IV) who survived for more than 2 days, using the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. Patients were classified into four groups: 919 patients (27.0%) in NYHA I, 1,007 patients (29.6%) in NYHA II, 767 patients (22.5%) in NYHA III, and 710 patients (20.9%) in NYHA IV. A multivariable logistic regression model adjusted for age, gender, Barthel Index, Charlson Comorbidity Index, and usage of inotropic therapy at admission was performed to evaluate the association between the surgical treatment and in-hospital mortality. Results Patients with higher NYHA classification were significantly older and were more likely to be female than those with lower NYHA classification. At admission, patients with higher NYHA classification had lower baseline activities and higher comorbidities, and also had more complications including stroke, shock and disseminated intravascular coagulation than those with lower NYHA classification. In-hospital mortality was seen in 406 patients (11.9%) in the entire cohort. The mortality rate significantly increased with the NYHA class (NYHA I, 3.6%; NYHA II, 8.4%; NYHA III, 11.9%; NYHA IV, 27.9%: p&amp;lt;0.001). According to the multivariable logistic regression analysis, surgical treatment was independently associated with lower in-hospital mortality (Odds ratio 0.395, 95% Confidence Interval 0.297–0.526; p&amp;lt;0.001). A fragmentated analysis in each NYHA classification showed that the survival benefit of surgical intervention was pronounced in patients with higher NYHA class (Figure). The limitation of our study was including the potential unmeasured confounders, which lead to overestimate the relationship between the surgical treatment and in-hospital mortality even after excluding the critically ill patients who died within 2 days and adjusting for the measured confounders. Conclusion Surgical treatment was associated with lower in-hospital mortality among the patients with IE complicated with HF, particularly among those with more advanced HF status. Our study implies that surgical treatment might be beneficial for the patients with advanced HF. Funding Acknowledgement Type of funding source: None

Infective endocarditis at a tertiary care hospital in South Korea

ObjectiveThe treatment of infective endocarditis (IE) has become more complex with the current myriad healthcare-associated factors and the regional differences in causative organisms. We aimed to investigate the overall trends,...

Early and intermediate outcomes for surgical management of infective endocarditis

ObjectiveThe treatment of active infective endocarditis (IE) presents a clinical dilemma with uncertain outcomes. This study sets out to determine the early and intermediate outcomes of patients treated surgically for active IE at an academic medical center.MethodsA retrospective chart review was conducted to identify patients who underwent surgical intervention for IE at our institution from July 1st, 2011 to June 30th, 2018. In-patient records were examined to determine etiology of disease, surgical intervention type, postoperative complications, length of stay (LOS), 30-day in-hospital mortality, and 1-year survival.ResultsTwenty-five patients underwent surgical intervention for active IE. The average age of the patients was 47 ± 14 years old and most of the patients were male (N = 15). The majority of the patients had the mitral valve replaced (N = 10), with the remaining patients having tricuspid (N = 8) and aortic (N = 7) valve replacements. The etiology varied and included intravenous drug use (IVDU), and presence of transvenous catheters. The 30-day in-hospital mortality was 4% with 1 patient death and the 1-year survival was 80%. The average LOS was 27 days ±15 and the longest LOS was 65 days.ConclusionsSurgical management of IE can be difficult and challenging however mortality can be minimized with acceptable morbidity. The most common complication was CVA. The average LOS is longer than traditional adult cardiac surgery procedures and the recurrence rate of valvular infection is not minimal especially if the underlying etiology is IVDU.

Abstract 255: Patterns of Addiction Treatment for Patients Undergoing Cardiac Surgery for Infective Endocarditis Associated with Intravenous Drug Use

Introduction: Over the last decade, the U.S. has seen an increase in the number of infective endocarditis (IE) cases requiring surgical intervention. Infective endocarditis is often caused by intravenous drug use (IVDU). Given the complexity of these cases, the association with IVDU and the current opioid epidemic, we sought to characterize the nature of addiction interventions for these patients peri-operatively. Methods: This is a retrospective review of patients who underwent cardiac surgery for IE associated with a history of IVDU from 2009 to 2016 at a tertiary care center in New Haven, Connecticut. Data was collected including which drugs patients used, consultations by social work and psychiatry, initiation of medical therapy for addiction (methadone, buprenorphine, naltrexone), harm reduction initiative (naloxone), and evidence of enrollment in a drug rehabilitation program in the post-operative period. Results: This study observed 56 patients with a history of IVDU who underwent surgical intervention for IE. Thirty patients had active drug use at the time of their surgery, and the rest was labeled as having a history of IVDU. Among the 30, 22 used at least heroin, including 8 who used heroin and cocaine, and 5 who used heroin along with 2 or more other drugs (benzodiazepine, PCP, street suboxone, cocaine, Percocet, marijuana). In terms of psychosocial interventions, 41 (73.2%) were seen by a social worker, and 38 (67.9%) were seen by a psychiatrist during their hospitalization. Fourteen patients (25%) were neither seen by a social worker nor a psychiatrist. Medical therapy was defined as the administration of methadone, buprenorphine, naltrexone or naloxone during the hospitalization. Twenty-one patients (37.5%) were prescribed methadone, 6 patients (10.7%) were prescribed buprenorphine, 14 (25%) were prescribed naloxone, and 1 (0.02%) was prescribed naltrexone. Twenty-six patients (46.4%) were not prescribed any of the aforementioned medications. A total of 15 patients went to a drug rehabilitation program (26.8%) upon discharge, 13 of whom had been seen by a social worker (86.7%), and 8 by a psychiatrist (53.3%). Conversely, among those who did not go to a rehabilitation program, only 23% were seen by a psychiatrist, and 67.5% were seen by a social worker. The programs described included 12-step group rehabilitation, narcotics anonymous and adherence to daily methadone programs. Conclusion: This study highlights the inconsistency in addiction interventions in patients with IVDU-associated IE. Some patients receive medical therapy and are consulted upon for their psychosocial factors, but this practice is inconsistent. Given than recidivism (relapse in drug use or recurrent endocarditis) is the leading cause of death in this population, standardized protocols for addiction interventions in these patients are of utmost importance with the aim to improve long-term survival.

Value of surgery for infective endocarditis in dialysis patients

ObjectivesTo determine the value of surgery for infective endocarditis (IE) in patients on hemodialysis by comparing the nature and invasiveness of endocarditis in hemodialysis and nonhemodialysis patients and their hospital and long-term outcomes, and identifying risk factors for time-related mortality after surgery. MethodsFrom January 1997 to January 2013, 144 patients on chronic hemodialysis and 1233 nonhemodialysis patients underwent valve surgery for IE at our institution. Propensity matching identified 99 well-matched hemodialysis and nonhemodialysis patient pairs for comparison of outcomes. ResultsStaphylococcus aureus infection was more common in hemodialysis patients than in nonhemodialysis patients (42% vs 21%; P < .0001), but invasive disease was similar in the 2 groups (47%; P = .3). Hospital mortality was 13% and 5-year survival was 20% for hemodialysis patients, 20% below that expected in a general hemodialysis population but 15% above that of hemodialysis patients treated nonsurgically for IE. For matched patients, hospital mortality was 13% for hemodialysis patients versus 5.1% for nonhemodialysis patients (P = .05), and survival at 1 and 5 years was 56% versus 83% and 24% versus 59%, respectively (P < .004). Use of an arteriovenous graft for dialysis access (P = .01) and preoperative placement of a pacemaker (P < .0001) were risk factors for late mortality in hemodialysis patients. For matched patients, freedom from reoperation was similar in the hemodialysis and nonhemodialysis groups (P > .9). ConclusionsIntermediate-term survival after surgery for IE in hemodialysis patients is substantially worse than that in nonhemodialysis patients, but only slightly worse than that in the general hemodialysis population and substantially better than that in hemodialysis patients with IE treated nonsurgically, supporting continued surgical intervention for IE.

Abstract TMP87: Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For?

Introduction: Ischemic and hemorrhagic stroke often complicate infective endocarditis (IE). Optimal timing of surgical intervention for IE with stroke remains controversial. We compared neurological outcomes of early and delayed valve surgery for IE complicated by stroke. Methods: We reviewed 73 patients with acute IE by Duke Criteria who underwent brain imaging (CT, MRI, or cerebral angiogram) before valve operations between December 2014 and August 2016. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis and delayed surgery as &gt;14 days. Neurological complication is defined as delirium &gt;72 hours after extubation and cessation of sedation, new ischemic or hemorrhagic stroke. Results: Among 73 patients who underwent valve replacement surgery, 71 had evidence of stroke on imaging: 54 patients with acute or subacute ischemic infarct, 9 patients with evidence of intracerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. The median time from IE diagnosis to surgery was 9 days. Forty patients had early surgery, and 33 patients had late surgery. Early surgery group had fewer patients with history of ischemic stroke (55% vs 79%, p=0.033), fewer acute or subacute infarcts on imaging (63% vs 88% p=0.016), but more native valve infections (73% vs 45%, p=0.018). The incidence of post-operative stroke was similar between both groups (2.5% vs 9%, p=0.32). In the delayed group, ischemic strokes occurred in 4 patients awaiting surgery. Hypertension and diabetes mellitus were associated with post-operative neurological complications (p&lt;0.05), but pre-operative stroke on imaging was not. Conclusion: In IE patients with acute stroke, early surgery does not appear to increase post-operative neurological complications.

Single Centre Review of Surgically Managed Infective Endocarditis

Purpose: Infective endocarditis (IE) is a life-threatening illness that requires early intervention. We sought to identify the outcomes of all patients who underwent surgical intervention for IE at an Australian tertiary hospital. Methodology: The study institution's Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database was searched for all patients who underwent valve surgery with active IE between 2000 and 2015. Additional data was obtained by reviewing medical records. Results: There were 133 patients who underwent surgical management of IE. Mean patient age was 54 ± 16 years. A history of IV drug use was present in 23% (31/133) of patients. The commonest infective agents were Staphylococcus aureus in 32% (42/133), of which 14% were MRSA (6/42), Streptococcus viridans in 15% (20/133), and Enterococcus faecalis in 13% (17/133). A single valve procedure was performed in 75% (100/133), while multiple valve procedures were performed in 25% (33/133). The surgical procedures were: aortic valve surgery in 68% (90/133), mitral valve surgery in 47% (63/133) and tricuspid valve surgery in 10% (13/133). Surgical mortality was 15% (20/133). On univariate analysis having emergency surgery (p = 0.003), cross clamp time (p = 0.015) and cardiopulmonary bypass time (p = 0.03) were identified as significant risk factors for mortality. On multivariable analysis emergency surgery (p = 0.021) was identified as a significant risk factor for mortality. Conclusion: Surgery for infective endocarditis is associated with substantial early mortality. Emergency surgery is associated with increased risk of mortality. A multidisciplinary approach with early referral to cardiothoracic surgery is indicated.

Clinical experience of infective endocarditis complicated by acute cerebrovascular accidents

To evaluate the clinical results of patients with infective endocarditis (IE) complicated by acute cerebrovascular accidents (CVAs). A total of 44 patients with IE complicated by CVA at admission were retrospectively analyzed in a single medical institute from 2005 to 2011. At the time of admission, 18 patients were diagnosed with hemorrhagic stroke, and 26 patients were diagnosed with ischemic stroke. Fifteen patients received surgical intervention during hospitalization. The hospital mortality rate was 38.9% for the hemorrhagic stroke group and 42.3% for the ischemic stroke group (p=0.821). The mortality rate was 33.3% for the surgical group and 44.8% for the nonsurgical group (p=0.531). At 30 days of hospitalization, 45.8% of the patients experienced an adverse event (defined as death due to organ failure, restroke, cardiogenic shock, or septic shock during the treatment period), and the attrition rate was 1.5% per day. Surgery performed after the adverse events increased mortality (80.0%) compared with surgery performed on patients with no adverse events (10.0%; p=0.017). A Cox regression analysis revealed that creatinine > 2mg/dL, diabetes, and staphylococcal infection were the risk factors of the adverse events. Early surgical intervention for IE with ischemic stroke may prevent adverse events, particularly in patients with impaired renal function, diabetes, or staphylococcal infection. A delay in operation of > 30 days is recommended after hemorrhagic stroke.

Early Operation for Endocarditis Complicated by Preoperative Cerebral Emboli Is Not Associated With Worsened Outcomes

Valve operations for patients presenting with infective endocarditis (IE) complicated by stroke are thought to carry elevated risk of postoperative complications. Our aim was to compare outcomes of IE patients who undergo surgical intervention early after diagnosis of septic cerebral emboli with outcomes of patients without preoperative emboli. All patients undergoing operations for left-sided IE between 1996 and 2013 at our institution were reviewed. Patients undergoing operations more than 14 days after embolic stroke diagnosis (n= 11) and those withpurely hemorrhagic lesions (n= 7) were excluded from the analysis. The study included 308 patients who were stratified according to the presence (STR, n= 54) or absence of a preoperative septic cerebral embolus (NoSTR, n= 254). Primary outcomes of interest were the development of a new postoperative stroke and 30-day mortality. Mean time to surgical intervention from stroke onset was 6.0 ± 4.1 days. Staphylococcus aureus(39% STR vs 21% NoSTR, p= 0.004) infection and annular abscess at operation (52% STR vs 27% NoSTR, p< 0.001) were more prevalent in STR patients. There wasno significant difference in 30-day mortality (9.3% STR vs 7.1% NoSTR, p= 0.57) or in the rate of new postoperative stroke (5 [9.4%] STR vs 12 [4.7%] NoSTR, p= 0.19) between groups. In addition, there was no difference in 10-year survival between groups (log-rank p= 0.74). Early surgical intervention in patients with IE complicated by preoperative septic cerebral emboli does not lead to significantly worse postoperative outcomes. Early surgical intervention for IE after embolic stroke warrants consideration, particularly in patients with high-risk features such as S aureus or annular abscess, or both.

Injection Drug Use and Outcomes After Surgical Intervention for Infective Endocarditis

Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and 180 days (hazard ratio [HR], 9.8; 95% confidence interval [CI], 2.7-35.3) but not before 90 days (HR, 0.38; 95% CI, 0.05-3.1) or after 180 days (HR, 1.8; 95% CI, 0.8-3.8). Among patients who injected drugs, reoperation and death contributed equally to the outcome, whereas among patients who did not inject drugs, reoperation for IE was far less common. Between 3 and 6 months after operation for IE, patients who inject drugs have a hazard of death or reoperation that is about 10 times that of patients who do not inject drugs. Before and after, the HRs are much smaller and not statistically significant.

Impact of Early Surgical Treatment on Postoperative Neurologic Outcome for Active Infective Endocarditis Complicated by Cerebral Infarction

The optimal timing of surgical intervention for infective endocarditis (IE) with cerebrovascular complications remains controversial because the risk of perioperative intracranial hemorrhage is still unclear. The aim of this study was to investigate the prevalence of acute cerebral infarction (CI) in patients with IE and its hemorrhagic risk after valve operations. We retrospectively evaluated 102 consecutive patients (35 with neurologic symptoms; 67 without neurologic symptoms) who underwent diffusion-weighted magnetic resonance imaging (DW-MRI) before valve operations for left-sided active IE between 2005 and 2010. The prevalence of acute CI and its postoperative neurologic outcome were evaluated. Acute CI was detected preoperatively in 64 of 102 (62.7%) patients. Of the 64 patients with acute CI, 34 underwent surgical treatment within 14 days after diagnosis of CI (early group), whereas the other 30 patients underwent operation after more than 14 days (delayed group). Postoperative CI deterioration was confirmed in 1 patient in each group. Furthermore, in 43 of the patients with acute CI who were followed with postoperative neuroimaging, hemorrhagic transformation was confirmed in only 1 patient in the delayed group. However new ectopic intracranial hemorrhage was confirmed in 2 patients in the early group and 3 patients in the delayed group. The risk of postoperative hemorrhagic transformation of preoperative acute CI was low, even in patients who underwent early operation. Our data suggested that there is no benefit for delaying surgical treatment beyond 2 weeks to prevent hemorrhagic transformation in patients with CI. However ectopic intracranial hemorrhage sometimes occurs regardless of the timing of surgical treatment.

Abstract 16736: Medical vs. Surgical Management of Perivalvular Abscess in Infective Endocarditis: A Propensity Analysis From the International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS)

Introduction Myocardial abscess is generally regarded as an indication for surgical intervention in infective endocarditis (IE). There is little information, however, comparing outcomes with medical vs. surgical management of such periannular complications of IE. This study used the database of the ICE-PCS to perform a propensity analysis, comparing one year mortality in patients with IE and abscess subjected to either medical or surgical treatment. Methods ICE-PCS enrolled 4794 patients between 2000 and 2006, from 64 centers in 28 countries. There were 699 cases of IE with abscess. A statistical model was built to predict surgery in this cohort.158 patients who underwent surgery for abscess were matched to 158 patients who did not. These 316 patients formed the basis of the analysis. Results In the unadjusted group of 699 patients, the one-year survival with medical treatment was 45%, vs. 67% with surgical management (p&lt;.0001). Differences favoring surgery were similar whether or not the patients had poor prognostic indicators (S. aureus infection; prosthetic valve involvement; CHF). Patients with strep viridans infection, however, had similar survival with medical or surgical management (70%, 14/20 vs.77%, 65/84). In the propensity analysis, the one-year survival with medical management was 44%, compared to 58% in the surgical group (p=.0021). (See graph). Conclusion One-year survival of IE patients with abscess was superior with surgical compared to medical management. These findings support current recommendations that surgical management of perivalvular extension of infection is generally the preferred approach. Patients with strep viridans infection, however, seem to fare equally well with medical or surgical treatment.

Corynebacterium diphtheriae endocarditis: a case series and review of the treatment approach

Infective endocarditis due to non-toxigenic Corynebacterium diphtheriae is uncommon; we report 10 cases occurring over a 14-year period in Auckland, New Zealand and review the approach for treatment. Eight of the 10 patients had known prosthetic valves or homografts in situ. Three patients required surgical intervention for infective endocarditis. Seven patients were treated with a combination of β-lactam and aminoglycoside, and one each was treated with a combination of vancomycin and an aminoglycoside, a β-lactam alone, and vancomycin alone. All patients survived and none relapsed. The antibiotic treatment of 46 previously reported cases was reviewed; patients treated with a β-lactam and aminoglycoside (n=25), and without the addition of an aminoglycoside (n=11) were compared. The differences in length of treatment within each group make the comparison of outcome (mortality, need for surgical intervention, disease and treatment complications) difficult. However, regardless of the length of treatment, there was no difference in mortality or need for surgical intervention between the two groups in the currently published cases. Current evidence suggests that endocarditis of either native or prosthetic valves, caused by penicillin-susceptible C. diphtheriae, demonstrates a favorable outcome when treated with either a β-lactam alone or in combination with an aminoglycoside. Patient-specific factors will determine which approach is more appropriate for each individual patient.