Surgical Treatment Of Infective Endocarditis Research Articles

Early Mortality Predictors in İnfective Endocarditis Patients: A Single-Center Surgical Experience.

Infective endocarditis is a disease that progresses with morbidity and mortality, afecting 3-10 out of 100,000 people per year. We conducted this study to review the early outcomes of surgical treatment of infective endocarditis. In this retrospective study, 122 patients who underwent cardiac surgery for infective endocarditis in our clinic between November 2009 and December 2020 were evaluated. Patients were divided into two groups according to in-hospital mortality. Demographic, echocardiographic, laboratory, operative, and postoperative data of the groups were compared. Between November 3, 2009, and December 7, 2020, 122 patients were operated for infective endocarditis in our hospital. Emergency surgery was performed in nine (7.3%) patients. In-hospital mortality occurred in 23 (18.9%) patients, and 99 (81.1%) patients were discharged. In-hospital mortality was related with older age, presence of periannular abscess, New York Heart Association class 3 or 4 symptoms, low albumin level, high alanine aminotransferase level, and longer cross-clamping time (P<0.05 for all). The presence of paravalvular abscess was the most important prognostic factor in patients operated for infective endocarditis.

Epidemiology of infective endocarditis in Africa: a systematic review and meta-analysis

The epidemiology of infective endocarditis in Africa is inadequately characterised. We therefore aimed to comprehensively summarise the available data for the incidence, risk factors, clinical pattern, microbiology, and outcomes of infective endocarditis in Africa. We did a systematic review and meta-analysis. We searched PubMed, Embase, African Index Medicus, and African Journals Online for all studies reporting primary data for the epidemiology of infective endocarditis in populations within Africa, published from inception to Jan 14, 2021, irrespective of the language. We used the search terms "endocarditis", "Africa", and the name of all African countries in the search strategy. We excluded articles that did not include primary data, primary studies with a small sample size (<30 participants), and those that report findings from before 1990. We recorded data for study characteristics, sample size, criteria used to define infective endocarditis, risk factors, potential entry site, clinical patterns, microbiology profile, outcomes including complications such as embolic events, heart failure, acute kidney injury, and death, and predictors of death. We used random-effects meta-analysis method to pool estimates. This study is registered with PROSPERO, CRD42021243842. We retrieved 2141 records from the database and bibliographic searches, of which a total of 42 studies were included in this systematic review. Rheumatic heart disease was the most common risk factor for infective endocarditis in adults (52·0% [95% CI 42·4-61·5]), whereas congenital heart disease was the most common risk factor for infective endocarditis in children (44·7% [29·5-60·5]). Microbiological testing (mostly blood cultures) was positive in 48·6% (95% CI 42·2-51·1) of patients with infective endocarditis, with Staphylococcus species (41·3% [95% CI 36·2-46·5]) and Streptococcus species (34·0% [29·0-39·3]) the most commonly identified microorganisms. The pooled rate of surgical treatment of infective endocarditis was 49·1% (95% CI 43·2-55·1). The pooled in-hospital mortality rate was 22·6% (95% CI 19·5-25·9). Other frequent complications included heart failure (47·0% [95% CI 38·2-56·0]), acute kidney injury (22·8% [18·8-27·0]), and embolic events (31·1% [22·2-40·7]). As the most prevalent risk factor in Africa, rheumatic heart disease should be central in interventions to reduce the burden of infective endocarditis on the continent. In tertiary hospitals with good access to cardiac surgery, the outcomes of infective endocarditis seem relatively similar to what has been reported in other parts of the world, especially in high-income countries. None.

Abstract 14341: Older Patients Do Well Following Surgical Treatment of Infective Endocarditis

Introduction: Evidence for the role of surgery in the management of infectious endocarditis (I.E.) is conflicting and there is no data relating specifically to the elderly subgroup. We hypothesised that for I.E., the elderly have different presentation, treatment profile and outcomes compared to the remainder of the adult population. Methods: We collected registry data on consecutive cases of IE treated in our tertiary centre over 10 years. Data for symptoms and signs, treatment, response, the development of complications (graded into four groups of severity) and outcome, were gathered. We identified characteristics particular to the elderly I.E. population compared to those of a younger age. Results: Of 107 patients, 50 were over 59 and 19 over 69 years of age. Risk factors for adverse outcome did not include age. Those over 69 more commonly had non-specific symptoms (e.g. weight loss and dyspnoea). Only of 37% the over 69 age group were treated surgically compared to 72% of those under 69. Across age groups the complication profile in surgically managed patients was higher than conservatively managed patients (since this is a higher risk subset). However, most strikingly, amongst the surgically managed patients, the outcomes in patients over 69 years compares well with all other age groups (Fig 1). Conclusion: The proportion of elderly patients treated surgically is lower than other age groups, reflecting understandable caution in surgical management of older patients. However, since the outcome in these patients compares favourably with all other age groups, we conclude that the surgical treatment of I.E. is an attractive option in carefully selected elderly patients.

Surgical treatment of infective endocarditis at comprehensive versus primary valve centers

BackgroundA recent expert consensus statement proposed designation of comprehensive and primary valve centers, with a recommendation that comprehensive centers house surgical skill and resources to treat patients with infective endocarditis (IE). We sought to compare outcomes of patients who underwent valve surgery for IE at comprehensive versus primary valve centers within a large health care system. MethodsWe reviewed 513 consecutive patients who underwent IE surgery at 8 hospitals (2 comprehensive and 6 primary valve centers) from 2014 to 2020. Outcomes from comprehensive and primary valve centers were compared after propensity score matching on the basis of patient characteristics, valve involvement, valve type, and IE treatment status. Multivariate logistic regression was used to identify risk factors for operative mortality. ResultsPropensity score matching generated comparable groups with similar mean Society of Thoracic Surgeons/Gaca IE risk scores among comprehensive and primary valve center cohorts. Comprehensive valve centers were more likely to perform the Bentall procedure (60.4% vs 21.7%; P < .01) when aortic root abscess was present and mitral valve repair (50.4% vs 26.3%; P < .01) in cases of mitral valve involvement. Operative mortality was significantly lower at comprehensive valve centers (6.2% vs 13.0%; P = .04), and multivariate logistic regression suggested that surgery at comprehensive valve centers was protective against operative mortality (odds ratio, 0.39; 95% confidence interval, 0.17-0.88; P = .02). Similar findings were present in a sensitivity analysis limited to patients with active IE only. ConclusionsAn increased risk for operative mortality was associated with surgery performed at primary valve centers compared with comprehensive valve centers. Referral or transfer of patients with IE and surgical indications to comprehensive valve centers should be considered.

Aortic valve endocarditis in patients with bicuspid and tricuspid aortic valves

ObjectiveTo determine the long-term survival and rate of reoperation after surgical treatment of infective endocarditis (IE) in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV). MethodsBetween 1997 and 2017, 210 patients underwent surgical treatment for native aortic valve endocarditis, including 51 patients with BAV (24%) and 159 patients with TAV (76%). Data were obtained from the Society of Thoracic Surgeons data warehouse and hospital medical record review, supplemented with surveys and national death index data for more complete follow-up. ResultsCompared with the TAV IE group, the BAV IE group was significantly younger (42 years vs 54 years) and had lower incidence rates of hypertension, coronary artery disease, and congestive heart failure (CHF). There were no significant between-group differences in postoperative stroke, sepsis, pacemaker requirement, or in-hospital mortality (2.0% vs 4.4%). Liver disease was a risk factor for operative mortality (odds ratio [OR], 13; 95% CI, 3.3-30; P = .0002). The 10-year survival rate was 64% for the BAV group versus 46% for the TAV group (P = .0191). Significant risk factors for long-term mortality were intravenous drug use (hazard ratio [HR], 4.5; P < .0001), preoperative renal failure requiring dialysis (HR, 4.13; P < .0001), CHF (HR, 1.7; P = .04), and liver disease (HR, 2.6; P = .02). The HR for BAV was 0.67 (95% confidence interval [CI], 0.3-1.4). The 10-year postoperative cumulative incidence of reoperation was significantly higher in the BAV patients compared with the TAV patients (5.7% vs 4.5%; P = .045) with an HR of 2.4 (95% CI, 0.8-7.1; P = .11) for BAV. ConclusionsBAV patients develop IE requiring surgery at a younger age than TAV patients, but have significantly better long-term survival. Early detection of BAV is important to prevent IE and provide aggressive surgical treatment should IE occur.

Zolpidem improves patients' sleep quality after surgical treatment for infective endocarditis: a prospective observational study.

The objective of this study was to investigate the efficacy of zolpidem for improving post-operative sleep quality among patients with infective endocarditis (IE) and to identify the potential risk factors for impaired sleep quality at 6months after surgery. Patients withIE who underwent surgical treatment were divided into two groups according to zolpidem usage. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to evaluate patients' sleep qualityand daytime sleepiness at baseline, which was the second day after transferal, and at 6months after surgery. Logistic regression was used to identify potential risk factors. There were 32 patients in the zolpidem group and 42 in the control group. The PSQI and ESS scores at 6months after surgery were significantly lower than those at baseline in both groups (P = 0.04). Additionally, 9 patients (28%) in the zolpidem group and 22 patients (52%) in the control group suffered poor sleep quality. Multivariate analysis identified age (odds ratio [OR] = 1.26, 95% confidence interval [CI]: 1.12-1.42), baseline PSQI score (OR = 2.66, 95%CI: 1.55-4.65), and no zolpidem usage (OR = 45.48, 95%CI: 3.01-691.23) as independent factors for poor sleep quality. Poor sleep quality after IE surgery was prevalent among patients even 6months after IE surgery. Age, baseline PSQI score and no zolpidem usage were independently associated with poor sleep quality. Therefore, zolpidem has the potential to be an effectivepart of a treatmentarsenal for poor sleep quality after surgical treatment for IE.

Surgical treatment for active infective endocarditis: progress and challenges

<p indent=0mm>Infective endocarditis (IE) is a challenging disease. In the past century, it has the highest mortality among all kinds of valvular heart diseases. Treatment for IE has developed over time from anti-infective therapy only to today’s active surgery. However, due to its characteristics of multisystem involvement and changeable clinical symptoms, early diagnosis, indication and timing of surgery, and evaluation of surgical risk remain urgent issues at present. By reviewing representative literature in the past <sc>20 years</sc> and combining them with our experience of surgical treatment for IE, we summarize the latest progress and challenges faced by active surgery for IE, and emphasize the importance of establishing IE multidisciplinary team in clinical practice.

Surgical treatment of infective endocarditis in intravenous drug abusers

BackgroundDespite current progress in antibiotic therapy and medical management, infective endocarditis remains a serious condition presenting with high mortality rates. It also is a life-threatening complication in patients with a history of chronic intravenous drug abuse. In this study, we analyzed our institutional experience on the surgical therapy of infective endocarditis in patients with active intravenous drug abuse. The aim of the study is to identify the predictive factors of mortality and morbidity in this subgroup of patients.MethodsBetween 2007 and 2020, a total of 24 patients (7 female, mean age 38.5 ± 8.7) presenting with active intravenous drug abuse underwent a surgical treatment for the infective endocarditis at out center. The primary endpoint was survival at 30th day after the surgery. The secondary composite endpoint included freedom from death, recurrent endocarditis, re-do surgery, and postoperative stroke during the follow-up period. Mean follow-up was 4.2 ± 4.3 years.ResultsStaphylococcus species was the most common pathogen detected in the preoperative blood cultures. Infection caused by Enterococcus species as well as liver function impairment were identified as mortality predictor factors. Logistic EuroSCORE and EusoSCORE-II were also predictive factors for mortality in univariate analysis. Survival at 1 and 3 years was 78 and 72% respectively. Thirty-day survival was 88%. 30-day freedom from combined endpoint was 83% and after 1 and 3 years, 69 and 58% of the patients respectively were free from combined endpoint. Five patients (20.8%) were readmitted with recurrent infective endocarditis.ConclusionIn patients presenting with active intravenous drug abuse, treatment of infective endocarditis should be performed as aggressively as possible and should be followed by antibiotic therapy to avoid high mortality rates and recurrent endocarditis. Early intervention is advisable in patients with an infective endocarditis and enterococcus species in the preoperative blood cultures, liver function deterioration as well as cardiac function impairment. Attention should be also payed to addiction treatment, due to the elevated relapse rate in patients who actively inject drugs. However, larger prospective studies are necessary to support our results. As septic shock is the most frequent cause of death, new treatment options, e.g. blood purification should be evaluated.

Surgical treatment for infective endocarditis in the ageing society: a nationwide retrospective study in Japan

ObjectiveThe current status of surgical treatment for infective endocarditis (IE) among very elderly people is unclear.MethodsWe extracted data on patients in Japan with community-acquired IE who were admitted and discharged...

Surgical therapy of infective endocarditis following interventional or surgical pulmonary valve replacement.

Percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits are at risk for infective endocarditis (IE). In children and adults with a congenital heart disease, a pulmonary valve implant is frequently necessary. Prosthetic valve endocarditis is a conservatively barely manageable, serious life-threatening condition. We investigated the results of surgical pulmonary valve replacements in patients with IE. A total of 20 patients with congenital heart disease with the definite diagnosis of IE between March 2013 and July 2020 were included in this single institutional, retrospective review. Infected conduits were 11 Melody, 5 Contegra, 3 homografts and 1 Matrix P Plus. All of the infected prosthetic material was removed from the right ventricular outflow tract up to the pulmonary bifurcation. Pulmonary homografts were implanted after pulmonary root resection as right ventricle-to-pulmonary artery conduits. All patients survived and were discharged infection-free. The mean time from the conduit implant to the operation for IE was 4.9 years [95% confidence interval (CI), 3.0-6.9]. The median intensive care unit stay was 3.0 days (95% CI, 2.0-4.7), and the median hospital time was 25.0 days (95% CI, 19.2-42.0). Median follow-up time was 204.5 days (range 30 days to 5 years) without death or recurrent endocarditis. The surgical treatment of IE of percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits is a safe and effective therapeutic concept. Early surgical referral of patients with suspicion of IE should be pursued to avoid sequelae such as right ventricular failure, septic emboli, intracardiac expansion and antibiotic resistance.

Increased glucose variability is associated with major adverse events in patients with infective endocarditis undergo surgical treatment.

BackgroundThis study aimed to investigate the prognostic value of glucose variability (GV) in predicting postoperative major adverse events (MAEs) in patients with infective endocarditis (IE) who underwent surgical treatment.MethodsThis retrospective observational study included a total of 381 consecutive patients who underwent surgical treatment in our institution from October 2007 to August 2019. The MAEs included all-cause death, stroke, myocardial infarction, acute heart failure, IE recurrence, acute renal failure and sepsis. Postoperative GV in the first 24 hours was measured by the mean 24-hour glucose, standard deviation, coefficient of variation (CV) and mean amplitude of glycemic excursions. Univariate and multivariate logistic regression analyses were performed to identify the independent association of GV with MAEs.ResultsOf the 381 patients, 79 (20.7%) developed MAEs. The 30-day mortality of the overall study cohort was 5.23%. The multivariate logistic regression analysis indicated that 24-hour GV, measured as the CV [odds ratio (OR) =1.49, 95% CI, 1.23–3.57, P=0.012], was significantly associated with MAEs in IE patients. For every 10% increase in 24‐hour CV, there was a 49% increase in the risk of MAEs. Furthermore, compared to patients in the low tertile of GV, patients in the top tertile of 24-hour GV had a higher 30-day mortality and an increased incidence of heart failure and hemodialysis as well as longer ventilation support.ConclusionsThe results of this retrospective investigation demonstrated that increased GV measured by CV is an independent predictor of postoperative MAEs in patients undergoing surgical treatment for IE.

Risk factors of early mortality after surgical treatment for infective endocarditis.

To explore the basic clinical characteristics and relevant factors affecting the early postoperative prognosis in patients with infective endocarditis (IE). A total of 702 patients with IE, who underwent surgery in Xiangya Hospital, Central South University from January 1981 to June 2019, were studied and the data were collected through the paper records and the hospital information system. The patients from January 1981 to June 2010 served as an early group (n=224), and other patients from July 2010 to June 2019 served as a recent group (n=478). Independent risk factors for early postoperative death were determined by logistic regression analysis. The mean age of the 702 patients was 36.7±16.1 years, and the male accounted for 68.1%. Preoperative stroke occurred in 71 patients (10.1%), and dialysis was done in 14 patients (2%) preoperatively. Streptococcus were the pathogenic bacteria in 172 patients, accounting for 59.5% of all positive blood culture results. In the early group, the percentage of IE combined with congenital heart disease was significantly higher than that in the recent group [77 patients (34.4%) in the early group vs 22 patients (4.6%) in the recent group; P<0.05]. Postoperative stroke occurred in 15 patients (2.1%), while 59 patients (7%) required new dialysis postoperatively because of renal insufficiency. Twenty-nine patient died in the post-operation, with 4.1% in 30-day mortality. Logistic regression analysis revealed that the high preoperative New York Heart Association (NYHA) grade of cardiac function (OR=3.22, 95% CI 1.50-6.88; P<0.01), postoperative stroke (OR=5.75, 95% CI 1.22-27.07; P<0.05), postoperative dialysis (OR=15.53, 95% CI 3.50-68.82; P<0.01), perivalvular abscess (OR=13.19, 95% CI 3.83-45.42; P<0.01) and multivalve involvement (OR=3.57, 95% CI 1.24-10.30; P<0.05) were the independent risk factors for early mortality. Streptococcus is the most common pathogenic bacteria in the patients with IE. Surgery for IE can obtain a satisfactory early outcomes. High preoperative NYHA grade of cardiac function, postoperative stroke, postoperative dialysis, perivalvular abscess and multivalve involvement are the independent risk factors for early mortality.

Surgical treatment for infective endocarditis over three decades: a nationwide study

Abstract Background An increasing number of patients with infective endocarditis (IE) are treated surgically over time. It is important to know how this affects patient outcome. Current studies are mainly from tertiary centres which may bias estimations of outcomes. We have therefore conducted a nationwide study of surgical outcomes during admission for IE over three decades. Purpose We set out to examine temporal trends in use of valve surgery for IE and these patients' characteristics and related outcomes in Denmark in the period 1998–2017. Methods Using Danish nationwide registries, we included patients with first-time IE (1998–2017). The study population was categorized into four groups of five-year intervals (1998–2002, 2003–2007, 2008–2012, 2012–2017). Annual number of patients with IE and the proportion who underwent valve surgery during admission were reported. Kaplan-Meier estimates and multivariable logistic regression analyses were used to compare the associated 30-day mortality risk between calendar periods. Kaplan-Meier estimates and multivariable adjusted Cox proportional hazard analyses were used compare the associated 1-year mortality risk between calendar periods. Results A total of 8,455 patients with first-time IE were identified in the period of 1998–2017 of which 1,906 (22.5%) underwent valve surgery (1998–2002; N=320, 2003–2007; N=468, 2008–2012; N=528, 2013–2017; N=595). The proportion of patients who underwent surgery was 21.5% in 1998 and 19.4% in 2017 (P=0.02 for trend). See figure. For patients undergoing surgery, the median age and proportion of males increased from 58.3 years (P25-P75: 48.2–67.4) and 69.1% to 66.7 years (P25-P75: 55.2–73.0) and 73.1% in 1998–2002 and 2013–2017, respectively. Patients had an increasing burden of comorbidities including diabetes (10.3% to 14.3%), hypertension (16.9% to 37.5%) and renal disease (9.1% to 9.6%) across calendar periods. The 30-day mortality risk for patients with IE who underwent valve surgery was 10.0% (1998–2002), 10.8% (2003–2007), 6.4% (2008–2012) and 8.5% (2013–2017), respectively (P=0.09). One-year mortality risk for patients with IE who underwent valve surgery was 16.7% (1998–2002), 21.2% (2003–2007), 15.2% (2008–2012) and 16.6% (2013–2017), respectively (P=0.08). The declining 30-day and 1-year mortality was statistically significant over time when adjusting for patient characteristics (P=0.01 and P≤0.0001, respectively). Conclusion From a nationwide, unselected cohort of patients with first-time IE, around 1/5 undergo surgery during admission. Surgical IE-cases are older and sicker now compared to 10–20 years ago. In spite of this, there was a trend towards a decreased associated 30-day and 1-year mortality over time. Our data show a lower rate of surgery in IE than in most prior studies and we believe that this is due to the nationwide, unselected nature of our study. Infective endocarditis and surgery Funding Acknowledgement Type of funding source: None

VINDICTIVE VEGETATION: A RARE CASE OF ISOLATED PULMONIC VALVE ENDOCARDITIS

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endocarditis can affect native or prosthetic heart valves and lead to significant multi-organ injury and mortality. We present a rare case of recurrent isolated pulmonic valve endocarditis (PVE) precipitating severe valvular regurgitation and septic emboli subsequently necessitating surgical intervention. CASE PRESENTATION: A 28 year-old male with history of HIV (CD4 493), Hepatitis C, and intravenous drug use (IVDU) was brought in by ambulance for altered mental status. He was noted to be afebrile, tachycardic to 141 beats/min, tachypnic to 25 breaths/min, and saturating 93% on room air. Laboratory analysis was significant for leukocytosis to 27.2 K/cumm, D-Dimer elevation to 4,321 ng/mL, and urinary toxicology screen positive for amphetamines. Evaluation with CT Thorax demonstrated acute right heart strain, bilateral pulmonary emboli, and regions of lung infarct. A transthoracic echocardiogram visualized a 1.8 cm x 1.2 cm vegetation on the pulmonic valve complicated by leaflet destruction and severe regurgitation. The patient was found to have Streptococcus Viridans bacteremia and was treated with six weeks of IV Penicillin G. A repeat echocardiogram confirmed a persistent 16mm x 4mm pulmonic vegetation, and he consequently underwent surgical valve replacement. Valvular pathology revealed necrosis, myxoid degeneration, and aggregates suspicious of bacterial colonies. Two months later, the patient returned with dyspnea. A large amount of vegetation obstructing flow through the pulmonic bioprosthetic was discovered, with evidence of severe valvular stenosis and interval development of right ventricular systolic dysfunction. Blood cultures grew E. Faecalis and he was treated with six additional weeks of antibiotics. He was hospitalized multiple times over the following year for heart failure symptoms, however was not a candidate for repeat valve replacement due to continuous IVDU. He succumbed to in-hospital PEA arrest and, despite resuscitation efforts, passed away. DISCUSSION: Right-sided endocarditis is infrequently encountered and is often associated with IVDU, HIV, congenital heart disease, and central venous catheters (1). There is scant data on isolated pulmonic valve involvement, which has an estimated prevalence of 1.5-2% of all endocarditis cases (2). While studies suggest that PVE often follows a benign course with appropriate antibiotic therapy, our case illustrates the severity of potential complications. Current guidelines suggest surgical management in patients with right-sided involvement who have persistent infection, evidence of severe valve dysfunction/heart failure symptoms, vegetation ≥ 2 cm, or for prevention of further septic emboli (3). CONCLUSIONS: Isolated PVE remains a challenging diagnosis as cardiac manifestations may initially be silent, emphasizing the need for heightened clinical suspicion in immunocompromised patients presenting with respiratory symptoms. Reference #1: Cahill TJ & Prendergast BD. Infective Endocarditis. Lancet. 2016; 387(10021):882-93. Reference #2: Chowdhury MA & Moukarbel GV. Isolated Pulmonary Valve Endocarditis. Cardiology. 2016;133(2):79-82. Reference #3: AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs, Pettersson GB, Coselli JS, et al. 2016 The American Association for Thoracic Surgery (AATS) Consensus Guidelines: Surgical Treatment of Infective Endocarditis: Executive Summary. J Thorac Cardiovasc Surg. 2017;153(6):1241-1258.e29. DISCLOSURES: No relevant relationships by Serena Ghanshani, source=Web Response No relevant relationships by Katherine Loomis, source=Web Response No relevant relationships by Andrea Lu, source=Web Response

Surgical treatment of infective endocarditis: Results in 831 patients from a single center.

This study evaluated surgical outcomes of infective endocarditis (IE), with particular attention to the impact of intravenous drug use (IVDU). Adult patients undergoing surgery for IE between 2011 and 2018 at a single center were included and stratified by IVDU. The primary outcome was overall survival. Secondary outcomes included postoperative complications and hospital readmissions. Kaplan-Meier and multivariable Cox regression were utilized for unadjusted and risk-adjusted survival analyses, respectively. Cumulative incidence function curves were compared for hospital readmissions. A total of 831 patients (mean age 55 years, 34.4% female) were operated on for IE, including 318 (38.3%) with IVDU. Cultures were most commonly positive for streptococcus (25.2%), methicillin-sensitive Staphylococcus aureus (17.7%), enterococcus (14.3%), or methicillin-resistant Staphylococcus aureus (8.4%). The most common procedures included isolated aortic valve repair/replacement (18.8%), aortic root replacement (15.9%), mitral valve repair/replacement (26.7%), aortic and mitral valve replacement (8.4%), and tricuspid valve repair/replacement (7.6%). Mean follow-up was 3.4 ± 2.4 years. Overall 5-year survival was 64% and was similar between IVDU and non-IVDU. Multivariable analysis demonstrated that IVDU was not associated with mortality risk. IVDU patients displayed higher rates of all-cause readmission (61.6% vs 53.9%; P = .03), drug-use readmission (15.4% vs 1.4%; P < .001), and recurrent endocarditis readmission (33.0% vs 13.0%; P < .001). The majority of patients undergoing surgical treatment of IE are alive at 5-years although readmission rates are high. IVDU is not a risk factor for longitudinal mortality although patients with IVDU are at higher overall readmission risk, driven largely by greater readmissions for drug-use and recurrent endocarditis.

Impact of Chronic Renal Failure on Surgical Outcomes in Patients With Infective Endocarditis

Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied. Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival. Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P < .05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P < .05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P < .001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively. In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

Outcome of surgery for acute infective endocarditis: does preoperative stroke have an impact on mortality?

Surgical therapy of infective endocarditis (IE) is challenging and can be associated with high mortality. In this study, we present the early outcomes of patients who underwent cardiac surgery for IE. From 2017 until 2019, 66 patients underwent surgical treatment for IE. Staphylococcus aureus infection was identified in 14 patients (21%). In the same period, about 813 valve replacement procedures were performed with 8% incidence of IE. Mean age was 66 ± 12years and 32% were females. Mean ejection fraction was 55 ± 9%. Seven patients (11%) had stroke due to septic embolism preoperatively. In 20 patients (30%), prosthetic valve endocarditis was an indication for reoperation. Thirty-day postoperative mortality and impact of preoperative stroke were analyzed. Thirty-day mortality was 17% (n = 11). Mean EuroSCORE I was 28 ± 22%. Mean cross clamp time was 63 ± 37min. Fourty patients (61%) underwent one-valve procedure, 25 patients (38%) had double-valve, and one (1%) triple-valve operation. All seven patients with preoperative neurologic dysfunction had unremarkable postoperative course without death or neurologic deterioration. Five of them had no worsening in neurological status, while 2 patients had slight improvement in speech. The comparison between the two groups (patients without preoperative neurological vs. patients with preoperative neurological dysfunction) revealed no significance in the postoperative mortality rate (18% vs. 0% with p = 0.26). Postoperative echocardiography revealed competent valve function in all cases. Surgical treatment for IE still remains a challenge with high morbidity and mortality. Patients with preoperative neurologic dysfunction due to septic embolism have good early postoperative results without increased mortality.

Current AATS guidelines on surgical treatment of infective endocarditis

Current AATS guidelines on surgical treatment of infective endocarditis

Current AATS guidelines on surgical treatment of infective endocarditis.

The 2016 American Association for Thoracic Surgery (AATS) guidelines for surgical treatment of infective endocarditis (IE) are question based and address questions of specific relevance to cardiac surgeons. Clinical scenarios in IE are often complex, requiring prompt diagnosis, early institution of antibiotics, and decision-making related to complications, including risk of embolism and timing of surgery when indicated. The importance of an early, multispecialty team approach to patients with IE is emphasized. Management issues are divided into groups of questions related to indications for and timing of surgery, pre-surgical work-up, preoperative antibiotic treatment, surgical risk assessment, intraoperative management, surgical management, surveillance, and follow up. Standard indications for surgery are severe heart failure, severe valve dysfunction, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis despite adequate antibiotic therapy for more than 5-7 days. The guidelines emphasize that once an indication for surgery is established, the operation should be performed as soon as possible. Timing of surgery in patients with strokes and neurologic deficits require close collaboration with neurological services. In surgery infected and necrotic tissue and foreign material is radically debrided and removed. Valve repair is performed whenever possible, particularly for the mitral and tricuspid valves. When simple valve replacement is required, choice of valve-mechanical or tissue prosthesis-should be based on normal criteria for valve replacement. For patients with invasive disease and destruction, reconstruction should depend on the involved valve, severity of destruction, and available options for cardiac reconstruction. For the aortic valve, use of allograft is still favored.

126. Cascade of Care for Opioid Use Disorder in Patients with Infective Endocarditis

BackgroundThe term “Cascade of Care” has been used to analyze care delivered by a health system for conditions such as HIV, hepatitis C, tuberculosis, and diabetes. It outlines sequential steps required to reach a specific outcome (i.e., viral suppression in the case of HIV). This allows to estimate the proportion of patients achieving each step and to identify gaps in care. Medication-assisted treatment (MAT) is integral in the treatment of patients with infective endocarditis (IE) and opioid use disorder (OUD). We propose a Cascade of Care aiming to identify fundamental milestones in the management of these patients.MethodsA retrospective cohort study examined patients with IE in the setting of OUD hospitalized between July 1, 2007 and January 1, 2015 to the Cleveland Clinic. We identified 4 key steps along the treatment cascade of these patients and estimated the proportion of patients: (1) evaluated by an addiction treatment service, (2) prescribed MAT while in-patient, (3) prescribed MAT at discharge, and (4) continued MAT at least 90 days after discharge.ResultsOf 273 patients with IE in the setting of OUD, 134 (49%) were evaluated by an addiction treatment service; 45 (17%) were prescribed MAT while in-patient; only 22 (8%) were prescribed MAT at discharge. At 90 days following discharge, there was evidence of continuing MAT for all 22 patients (8%).ConclusionDescribing the process of addiction treatment for patients with IE and OUD in the format of a cascade of care provides a powerful quantitative method to identify gaps in care and can be used as a resource to implement interventions to address losses. We found only 8% of these patients continued MAT in the community after discharge. This study provides an estimate of how compromised the potential benefits from medical and surgical treatment for IE are by the lack of an effective approach to OUD after hospital discharge. Disclosures All authors: No reported disclosures.