Valvular Endocarditis Research Articles

Relapse of infective endocarditis after cardiac implantable electronic device removal compared to a conservative strategy

Abstract Background According to current guidelines, complete removal of cardiac implantable electronic device (CIED) should be considered in patients with valvular infective endocarditis (IE), accounting for the identified pathogen and need for valve surgery (Class IIa recommendation). Unselected longitudinal data are needed to assess this strategy. Purpose To examine IE readmission after IE discharge according to status of CIED removal in patients with conservatively treated IE. Methods Using Danish nationwide registries, we identified patients aged ≥18 years with first-time IE from 2010-2021. We included patients with conservatively treated IE and a CIED, who were alive at IE discharge. Patients who underwent CIED removal during IE admission were compared to those without removal, examining the study outcome of IE readmission within six months after IE discharge. An initial blanking period of 14 days was applied after IE discharge. The Aalen-Johanson estimator and multivariable Cox regression models were used to determine cumulative incidences and adjusted hazard ratios (HRs) of IE readmission according to status of CIED removal, respectively. Results Among 6,843 patients with first-time IE, 5,731 (83.7%) were conservatively treated. Of these, 1,201 (21.0%) had a CIED, of which 205 (17.1%) died during IE admission. Thus, the final study population comprised 996 patients alive at IE discharge. The median age of the study population was 75.5 years (interquartile range [IQR]: 67.9-82.0), and 753 (75.6%) were males. In total, 574 (57.6%) patients underwent CIED removal during IE admission. Patients who underwent CIED removal were younger, compared to patients without CIED removal, 73.1 years (IQR: 65.7-79.1) versus 79.0 years (IQR: 71.3-85.1), respectively. The six-month cumulative incidence of IE readmission was 2.0% (95% confidence interval [CI]: 1.1-3.5%) in patients who underwent CIED removal versus 6.1% (95% CI: 4.0-8.9%) in patients without CIED removal (P-value=0.001) (Figure 1). CIED removal was associated with a significantly lower six-month rate of IE readmission, compared to no CIED removal (HR: 0.36 [95% CI: 0.17-0.77]). Relapse bacteraemia (including IE) with the same microorganism as first-time IE occurred in 2.2% of patients who underwent CIED removal and in 5.4% of patients without CIED removal. Staphylococcus aureus was the most common microorganism in 33.3% of patients with relapse bacteraemia who underwent CIED removal. Conclusions In this nationwide study, the six-month rate of infective endocarditis (IE) readmission was three-fold lower in patients who underwent cardiac implantable electronic device (CIED) removal, compared to patients without CIED removal. The current findings suggest that CIED removal is associated with lower risk of relapse of IE in patients with conservatively treated IE. These results are in line with current guideline recommendations. However, more randomized clinical trial data are needed.

Aortitis Secondary to Prosthetic Valve Endocarditis: A Rare Complication Unveiled

Abstract Introduction Aortitis includes both infectious and non-infectious inflammation of the arterial wall. Infectious forms have a worse prognosis, necessitating immediate diagnosis and treatment. We report a case of a patient with prosthetic valve endocarditis complicated with infectious aortitis and multiple embolic lesions, ultimately leading to death. Case presentation An 81-year-old man with an aortic valve bioprosthesis (Intuity 27 mm) presented with fever, dysuria, and ankle swelling. Laboratory showed leukocytosis, anemia, elevated NT-proBNP, and C-reactive protein. Echocardiography revealed a hyperechogenic mass on the bioprosthesis, confirmed as prosthetic endocarditis by transesophageal echocardiography, which also showed an aortic bulb aneurysm and a 9 mm arterial wall thickening. Blood cultures were positive for Staphylococcus aureus, and intravenous antibiotics were started. Thoracic computed tomography confirmed aortic root dilation and mural thickening, indicating infectious aortitis with multiple embolic lesions in the spleen and kidneys. The patient then suffered an intestinal sub-occlusion. The Heart Team decided against cardiovascular surgery due to frailty and high surgical risk. Despite initial hemodynamic stability, his condition deteriorated, leading to death. Conclusion This case presents a challenging scenario of prosthetic valvular endocarditis complicated by infectious aortitis, aortic aneurysm, and multiple thromboembolic lesions in a high-risk patient, ultimately resulting in death.

Cutibacterium Species Valvular and Cardiac Device-Related Infective Endocarditis: Contemporary Data From the GAMES Prospective Cohort (2008-2023).

Information on infective endocarditis (IE) caused by Cutibacterium spp. is limited and new Duke-International Society for Cardiovascular Infectious Diseases (ISCVID) criteria have not yet been properly assessed. We examined clinical characteristics, outcomes, and performance of diagnostic tests for Cutibacterium valvular and cardiac implantable electronic device-related IE (CIED-IE). Data corresponding to all episodes of Cutibacterium IE recorded from 2008 to 2023 in a prospective national cohort including 46 Spanish hospitals were examined. Possible IE cases were reassessed using the new criteria. The sensitivity of blood cultures, valvular and CIED cultures, and polymerase chain reaction of the 16S rRNA gene and sequencing (16SPCR) was evaluated. Of 6692 episodes of IE, 67 (1%) were caused by Cutibacterium spp. with 85% affecting men. Of these, 50 were valve-related (45 prosthetic, 5 native) and 17 CIED-related. The new criteria identified 8 additional cases and reclassified 15 as definite IE. Intracardiac complications (abscess, pseudoaneurysm, perforation, or intracardiac fistula) occurred in 23 of 50 (46%) valvular IE episodes, leading to 18% mortality, and up to 40% mortality if surgery was indicated but could not be performed. All CIED-IE cases underwent device removal and no deaths were recorded. Positive diagnosis rates for blood cultures, valve/device cultures, and 16SPCR were 52%, 70%, and 82%, respectively. Cutibacterium IE is a rare yet potentially life-threatening condition that warrants a high index of suspicion in men with endovascular prosthetic material. The new Duke-ISCVID criteria and molecular techniques are useful for its diagnosis. Considering a significant complication rate, cardiac surgery and removal of CIEDs play a key role in reducing mortality.

HALF DOSE THROMBOLYSIS IN INTERMEDIATE – HIGH RISK PULMONARY EMBOLISM WITH TRICUSPID VALVE MOBILE MASS: A BAIL OUT STRATEGY

Abstract A 82–year–old previously healthy male was referred to the emergency department complaining sudden onset dyspnea and witnessed syncope complicated by head trauma. Recurrent dizziness occurred previously. No history or drug consumption noted. On admission: heart rate 90 beats/min, blood pressure 110/60 mmHg, respiratory rate 25 breaths/min, oxygen saturation 87% in room air, normal body temperature. No lower extremities tenderness or swelling reported. Consistent with peripheral blood oxygen saturation levels, arterial blood gas analysis showed hypoxemia and respiratory alkalosis. Laboratory exams were significant for thrombocytopenia (89.000 cells/L), elevated cardiac troponin T levels (222 ng/L) and natriuretic peptide (NT pro–BNP 3944 pg/mL). Head CT excluded acute cerebral hemorrhage. At the electrocardiogram, signs of RV strain were present (biphasic T–waves in V1–V3 leads, S1–Q3–T3). Transthoracic echocardiography (TTE) showed dilated RV with hypokinetic free wall, “D–shaped” LV, “60/60” sign and a mobile filiform mass crossing the tricuspid valve plan in the right atrium (fig. 1). The patient did not present structural valvular abnormalities or endocarditis–related risk factors. CT pulmonary angiography detected a “saddle” PE and extensive thrombosis in inferior vena cava. After unfractioned heparin (UFH) bolus, the patient was transferred to our intensive care unit and balancing risks and benefits the chosen treatment option consisted in half dose systemic thrombolysis (50 mg rtPA in 60’’; 10 mg as loading dose in 2’). Because of potential harmful effects in thrombocytopenia and recent head trauma, UFH was temporarily withheld and started again after 1 hour. The day after, a beside TTE showed complete tricuspid thrombus resolution, a significant decrease in RV/LV ratio and systolic pulmonary artery pressure (fig. 2). Apart from small hematomas, no bleedings were reported. The patient was shifted to the ward on the next day and following course was uneventful. On day 4 a direct oral anticoagulant (Dabigatran 110 mg) was started. Abdominal and inferior limb–deep–venous ultrasound were both negative for pathological reports. A total body CT was scheduled to exclude silent malignancies at discharge. Take home message: in intermediate–high risk PE, half dose systemic fibrinolysis strategy is controversial since its potential benefit is counterbalanced by concerns about major bleedings, but increasing data suggest its efficacy with low risk profile.

Acute heart failure in patients with valvular infective endocarditis: a one-year consecutive cohort from a Spanish tertiary centre

Abstract Funding Acknowledgements None. Background Infective endocarditis (IE) is associated with substantial morbidity and mortality. Acute decompensated heart failure (AHF) is a frequent complication of IE and it is often an indication for urgent cardiac surgery. Purpose The aim of this study was to describe clinical data and short term outcomes of patients admitted for valvular IE complicated with AHF. Methods We collected data from all the patients with IE admitted or referred to our Spanish tertiary centre from September 1st, 2022 to August 31st, 2023. Patients with non-valvular IE were not included. Results Two patients did not consent to participate in the study. 87 consenting patients were included. Of them, 38 (44%) presented with AHF, of whom 14 (16.1%) had acute pulmonary oedema, and 6 (6.9%) suffered cardiogenic shock. Mean age was 67.4 years old in the AHF group vs 64.0 in patients without AHF (non significant), 74% of male sex in both groups, Charlson Comorbidity Index of 4.9 vs 5.6 points (n.s.); prosthetic-valve endocarditis was more frequent in the AHF group compared to patients without AHF (42% vs 28%, p < 0.05). Urgent cardiac surgery was indicated in 91% of patients with AHF vs 44% of patients without heart failure (p < 0.01); when indicated, surgery was eventually performed in 65% vs 57% of the patients (n.s.). In AHF patients with surgical indication, in-hospital mortality rate was significantly higher in those that did not undergo surgery (64% vs 16%, p < 0.01). Compared to native-valve IE, prosthetic-valve IE was associated with higher rates of AHF (42% vs 28%, p < 0.05). In-hospital mortality rate was significantly higher in AHF patients (33.3% vs 3.0%, p < 0.01). Acute pulmonary oedema and cardiogenic shock patients had the highest in-hospital mortality (respectively, 43% and 67%). Similarly, mortality rate 30 days after hospital discharge was higher in the AHF group (16.0% vs 6.3%, p < 0.05). Conclusions In this population, presentation with AHF was associated with worse short-term outcomes. Surgery was indicated in the majority of AHF patients, and not performing it was associated with worse outcome.

Case reports involving coinfection with Avibacterium paragallinarum and Ornithobacterium rhinotracheale in broiler chickens and Avibacterium endocarditis in broiler breeding hens in Poland

ABSTRACT The study describes three clinical cases of infection with Avibacterium spp.. In case no. 1, respiratory clinical signs and high mortality (0.7–4.2% daily; total 21.2%) in Ross 308 broiler chickens were shown to be caused by coinfection with sequence type 9 of O. rhinotracheale presumptive serotype A and A. paragallinarum presumptive serotype B. The identical (pulsed-field gel electrophoresis) restriction pattern (pulsotype) of seven A. paragallinarum isolates indicated that infectious coryza in broilers was caused by the same clone. In cases 2 and 3, sudden increased deaths in Ross 308 broiler breeders (especially males) with lesions in the endocardium (valvular or mural endocarditis) were shown to be caused by A. endocarditis. Among nine antibiotics tested, florfenicol was the only antibiotic to which all A. paragallinarum and O. rhinotracheale isolates were susceptible. Out of the eight antibiotics tested, 11 A. endocarditis isolates from both clinical cases of infective endocarditis were susceptible to penicillin, amoxicillin, doxycycline and florfenicol. The A. endocarditis isolates tested in both clinical cases had different PFGE patterns (pulsotypes), but identical within a case. The causes of infectious coryza and infective endocarditis in the cases presented have not been determined. In the prevention of infectious diseases in large-scale livestock farming, it is very important to follow the rules of biosecurity.

Which trial do we need? Percutaneous mechanical aspiration versus medical management alone for treatment of right-sided valvular infective endocarditis

Which trial do we need? Percutaneous mechanical aspiration versus medical management alone for treatment of right-sided valvular infective endocarditis

Fifth-time redo mitral valve replacement via right thoracotomy under systemic hyperkalemia cardiopulmonary bypass without aortic cross-clamp

The surgical management of prosthetic valvular endocarditis (PVE) can be challenging. We report a case of a 46-year-old female patient who had a history of four cardiac operations. We chose a mitral valve replacement via right thoracotomy to enable optimal exposure of the mitral valve (MV). Because of multi-reoperations, we employed systemic hyperkalemia for cardiac arrest to protect the heart during cardiopulmonary bypass (CPB) without aortic cross-clamping. Here, we present a complex operation that performed management of CPB under hyperkalemia and the patient had a good postoperative recovery.

Abstract 17621: Acute Coronary Syndrome Due to Septic Emboli From Infective Endocarditis

Case Description: A 34-year-old female with a history of IV drug use and valvular infective endocarditis requiring multiple valve replacements presented with weakness and abdominal pain. She was found to be in septic shock requiring vasopressors and antibiotics. EKG was initially without ischemic changes. Imaging revealed multiorgan infarction including the spleen, left kidney, and parietal and temporal lobes of the brain with concomitant subarachnoid hemorrhage. TTE showed multiple masses on the mitral valve and new stenosis of the recently replaced tricuspid valve, concerning for multi-valvular involvement. LV systolic function was normal. Blood cultures were positive for MRSA and Strep agalactiae. Severe troponin elevation along with diffuse ST elevations in V3-6 prompted cardiology consultation, however intervention was deemed inappropriate due to presence of subarachnoid hemorrhage, thrombocytopenia and multiorgan failure. The patient was soon transitioned to comfort care after a discussion with family. Discussion: Acute coronary syndrome (ACS) secondary to infective endocarditis is a rarely cited phenomenon. Standardized management and treatment for ACS is difficult in the setting of co-existing multiorgan failure. In this case, our patient with infective endocarditis subsequently developed ACS secondary to septic emboli from large perivalvular vegetations. We emphasize vigilance for acute coronary events during infective endocarditis without source control.

Abstract 16036: Concomitant Culture-Negative Left-Sided Native Valve Endocarditis With Splenic Emboli and Babesiosis: A Case Report

Description of Case: A 76-year-old man with type 2 diabetes and a previously drained hepatic abscess presented with 3 days of fevers and chills associated with dizziness, weakness, and fatigue after hiking at a New York State Park. He denied any shortness of breath, chest pain, abdominal pain, diarrhea, skin rashes, insect bites, IV drug use, recent travel or sick contacts but reported having dental work one month prior to admission. Initial vital signs were notable for a fever of 38.4°C with a blood pressure of 145/76, heart rate of 90, and physical examination was unremarkable. Extensive laboratory studies were drawn, which initially were notable for normocytic anemia, thrombocytopenia, low haptoglobin and elevated lactate dehydrogenase. Empiric antibiotics were initiated as the patient met criteria for systemic inflammatory response syndrome (SIRS). CT abdomen and pelvis was remarkable for right-sided spleen with polysplenia and multiple peripheral wedge-shaped splenic infarcts. A transthoracic echocardiogram (TTE) was inconclusive for infective endocarditis (IE). A subsequent transesophageal echocardiogram (TEE) showed vegetations on the aortic and mitral valves with mild regurgitation respectively. After cardiothoracic surgery evaluation, he was deemed not a surgical candidate. Blood and urine cultures remained negative, but the Babesia antibodies IgM and IgG antibodies, and Babesia microti PCR was detected. He was started on atovaquone 750 mg twice daily and azithromycin 250 mg once daily for 10 days for babesiosis. He was discharged on vancomycin 1g every 12 hours and ceftriaxone 2g every 24 hours for a total of 6 weeks for empiric IE treatment given splenic emboli. Discussion : We describe a rare case of fever caused by culture-negative mitral and aortic valvular endocarditis with splenic emboli and babesiosis. Recent dental work and hiking outdoors in the Northeast United States of America were the key predisposing factors. Given splenic infarcts, pursuing a TEE was pivotal in ascertaining the diagnosis. The patient received empiric IE treatment for gram-positive cocci, HACEK organisms and babesiosis with improvement of symptoms. Identifying and treating unusual causes of fever and SIRS are crucial in reducing mortality and morbidity.

Postmortem Evaluation of Cardiac Valvular Disease in Bald Eagles (Haliaeetus leucocephalus) and a Golden Eagle (Aquila chrysaetos).

Limited data are available regarding cardiac diseases in birds of prey despite their prevalence in these avian species. Literature regarding valvular lesions in birds of prey is scarce and includes single reports of left atrioventricular valvular endocarditis in an adult, free-ranging, male bald eagle (Haliaeetus leucocephalus) and aortic valvular endocarditis in an adult, free-ranging, female red-tailed hawk (Buteo jamaicensis). The purpose of this study was to evaluate the prevalence, signalment, gross necropsy findings, and histologic lesions of valvular lesions in eagles. In this retrospective study, necropsy reports for 24 free-ranging and captive eagles were evaluated over a 15-year period (July 3, 2006-February 28, 2021). Six (25%; 95% confidence interval: 8.9-58.9) birds, 5 bald eagles and 1 golden eagle (Aquila chrysaetos), met the inclusion criteria. Five (83.3%) of the 6 birds had valvular degeneration, 2 (33.3%) had endocarditis, and Staphylococcus aureus was cultured from 1 (16.7%) of the endocarditis cases. The 6 eagles with valvular lesions were all captive adults. Four of the birds were female (66.7%), and the aortic and left atrioventricular valves were equally affected. Acute or chronic cerebral infarcts were present in all 6 birds. Valvular cardiac disease should be considered as a differential diagnosis in eagles exhibiting respiratory distress, neurologic signs, syncope, or in cases of sudden death.

Transcatheter vacuum aspiration of valvular and lead related infective endocarditis

BackgroundTranscatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes. MethodsPubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed. ResultsData from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50–85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each. ConclusionsTranscatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

Follow the heart: A tale of possible infective endocarditis in a patient co-infected with Methicillin-resistant Staphylococcus aureus and Severe Acute Respiratory Syndrome Coronavirus 2

Abstract Introduction Methicillin-resistant Staphylococcus aureus (MRSA) is a leading pathogen responsible for bacteremia and valvular endocarditis. In patients with Coronavirus Disease 2019 (COVID-19), MRSA co-infection represents a challenging scenario, with increased morbidity and mortality. Case presentation We present a case of possible valvular endocarditis in a patient with acute COVID-19 and MRSA bacteremia. A 75-year-old woman presented with severe symptomatic aortic stenosis and moderate mitral stenosis. During hospitalization, she developed COVID-19 pneumonia with acute respiratory failure, and temporal and frontal intraparenchymal cerebral hemorrhage. Blood cultures were positive for MRSA, and the patient was started on a specific antibiotics regimen. The patient subsequently developed multi-organ failure and was transferred to the intensive care unit. Repeated computed tomography of the brain was consistent with a new occipitotemporal cortical hypodensity. Transthoracic echocardiography (TTE) showed a small (4 x 4 mm) mass attached to the aortic valve, but with TTE features inconclusive for infective endocarditis. The patient was scheduled for transesophageal echocardiography, but she suffered cardiac arrest, with no response to resuscitation maneuvers. Conclusions This case reveals the diagnostic and therapeutic challenges raised by MRSA and COVID-19 coinfection in a patient with preexisting valvular heart disease.

A RETROSPECTIVE ANALYSIS OF THE MORBIDITY AND MORTALITY OF CAPTIVE NORTHERN BALD IBIS (GERONTICUS EREMITA), AFRICAN SACRED IBIS (THRESKIORNIS AETHIOPICUS), AND SCARLET IBIS (EUDOCIMUS RUBER) HOUSED AT THE LONDON ZOO FROM 2000 TO 2020.

Necropsy (n = 144) and medical (n = 121) records of captive northern bald ibis (NBI; Geronticus eremita), African sacred ibis (ASI; Threskiornis aethiopicus), and scarlet ibis (SCI; Eudocimus ruber) housed at the Zoological Society of London's London Zoo (LZ) from 2000 to 2020 were reviewed. Pododermatitis was a common cause of morbidity in all species (79 cases in 247 examinations). Trauma (58 of 144), the majority being caused by suspected collisions with stationary objects in the zoo's habitats, infectious diseases (32 of 144), predominantly valvular endocarditis (10 of 32), and aspergillosis (9 of 32) were major causes of mortality. The odds of a morbidity being related to toxicosis were 4.4 times greater in NBI than for ASI (95% CI, 1.5-13.3; P < 0.05); all cases in the NBI were plumbism. Overall, females of all species had 3.4 times greater odds of undetermined morbidity than males (95% CI, 1.5-7.9; P < 0.05), and the majority (16 of 25) were birds that were thin without an apparent cause. Nestlings had 11.3 times greater odds of nutritional morbidity than adults (95% CI, 1.7-73.0) and 5.5 times greater than juveniles (95% CI, 0.7-41.0; P < 0.05). These data have identified areas that require further study in the population of NBI, ASI, and SCI held at LZ.

A review article on avian Erysipelas infection: An occupational disease of one health importance

This review article was designed to spotlight on erysipelas infection of poultry regarding the disease history and nomenclature, the bacterium, virulence factors and pathogenicity, susceptibility, infection and transmission, pathology, human infection, laboratory diagnosis, and the prevention and control. Erysipelas is an acute emerging and occupational disease that affects a wide range of birds especially turkeys. The disease is caused by a bacterium, Erysipelothrix rhusiopathiae (E. rhusiopathiae), which is a ubiquitous pathogen in the environment. Infection with E. rhusiopathiae is more common in adults than young birds and usually occur through mechanical skin injuries. Erysipelas in acute stage causes sudden death of infected birds, while some birds may show darkening of the skin or cyanosis in the head region and sharp drop in egg production. In post-mortem lesions, birds with E. rhusiopathiae show septicaemic picture, haemorrhages all over the body, valvular endocarditis, diffuse enlargement of internal organs, enteritis, and arthritis. The disease in human is known as erysipeloid and it mostly affects persons in direct contact with infected birds or contaminated poultry products. Strict biosecurity measures and treatment especially with penicillin derivatives are crucial for erysipelas control in infected birds. Living and inactivated vaccines for turkeys and other species of birds are used for prophylaxis.

Enterococcus casseliflavus infection in a captive Southern Cassowary (Casuarius casuarius): clinical and post-mortem findings.

An adult 22-year-old, male southern cassowary (Casuarius casuarius) presented for lethargy, dysorexia and soft feces. Clinical findings under chemical immobilization were unremarkable except for heterophilic toxic changes on blood smear, reduced albumin/globulin ratio and potentially elevated liver parameters. The animal was treated for suspected hepatobiliary insufficiency and received supportive treatment with daily subcutaneous fluids and medication and was monitored with a quality-of-life assessment. It was eventually euthanized after further deterioration. Post-mortem examination revealed vegetative valvular endocarditis, bile duct obstruction, cholangiohepatitis and splenitis with intralesional Enterococcus casseliflavus isolated. This is a first documented case of E. casseliflavus infection in a bird with multiorgan involvement.

Pathology of vegetative valvular endocarditis associated with ß-haemolytic Streptococci in pigs

Pathology of vegetative valvular endocarditis associated with ß-haemolytic Streptococci in pigs

Is Less Always More? A Prospective Two-Centre Study Addressing Clinical Outcomes in Leadless versus Transvenous Single-Chamber Pacemaker Recipients.

(1) Background: Leadless (LL) stimulation is perceived to lower surgical, vascular, and lead-related complications compared to transvenous (TV) pacemakers, yet controlled studies are lacking and real-life experience is non-conclusive. (2) Aim: To prospectively analyse survival and complication rates in leadless versus transvenous VVIR pacemakers. (3) Methods: Prospective analysis of mortality and complications in 344 consecutive VVIR TV and LL pacemaker recipients between June 2015 and May 2021. Indications for VVIR pacing were “slow” AF, atrio-ventricular block in AF or in sinus rhythm in bedridden cognitively impaired patients. LL indication was based on individualised clinical judgement. (4) Results: 72 patients received LL and 272 TV VVIR pacemakers. LL pacemaker indications included ongoing/expected chronic haemodialysis, superior venous access issues, active lifestyle with low pacing percentage expected, frailty causing high bleeding/infectious risk, previous valvular endocarditis, or device infection requiring extraction. No significant difference in the overall acute and long-term complication rate was observed between LL and TV cohorts, with greater mortality occurring in TV due to selection of older patients. (5) Conclusions: Given the low complication rate and life expectancy in this contemporary VVIR cohort, extending LL indications to all VVIR candidates is unlikely to provide clear-cut benefits. Considering the higher costs of LL technology, careful patient selection is mandatory for LL PMs to become advantageous, i.e., in the presence of vascular access issues, high bleeding/infectious risk, and long life expectancy, rendering lead-related issues and repeated surgery relevant in the long-term perspective.

Is less always more? A prospective two-centre study addressing clinical outcomes in leadless versus transvenous single-chamber pacemaker recipients

Abstract Background Transvenous (TV) pacemakers are a well established treatment of bradyarrhythmias yet their complications, namely bleeding, infection and pneumothorax, still pose challenges to modern cardiology. This applies particularly to the older patient subgroup requiring single-chamber pacing due to comorbid atrial fibrillation (AF). Furthermore, conditions such as superior venous access issues, high infectious, or bleeding risk may complicate or preclude transvenous lead implantation. While VVIR leadless (LL) pacemakers aim to tackle these shortcomings, a comparison with contemporary single-chamber TV cohorts is currently lacking thus hindering a clear definition of the scope of LL pacing in clinical practice. Purpose To prospectively analyse survival and complication rates in leadless versus transvenous single-chamber pacemaker recipients. Methods This is a prospective analysis of 344 consecutive patients who received single-chamber TV or LL pacemakers between June 2015 and May 2021 in two tertiary cardiology centres. Indications for single-chamber pacing were “slow” AF, atrio-ventricular block with comorbid AF (either permanent or accepted as “destination rhythm”) or with sinus rhythm in bedridden cognitively impaired patients. LL indications were ongoing or expected chronic haemodialysis (6.9%), superior venous access issues such as occlusion (11.1%) or need for its preservation (9.7%), active lifestyle with low amount of pacing expected (22.2%), frailty causing high bleeding and infectious risk (23.6%), as well as recent valvular endocarditis (2.8%) or implantable electronic device infection requiring extraction (5.6%). Results 72 patients (20.9%) received LL and 272 (79.1%) TV single-chamber pacemakers. In keeping with LL indications, diabetes and ongoing haemodialysis were more prevalent in the LL population. No significant difference in overall complication rate was observed between LL and TV patients (5.6% vs. 5.1%, p=0.33) apart from haematomas, which occurred more frequently in the LL population. Only 1 haematoma in the TV group required surgical reintervention. TV recipients survival was lower with greater cardiovascular mortality, likely due to selection of significantly older patients. Conclusions Given the limited complication rate observed in this contemporary single-chamber TV cohort and low life expectancy of this particular population, extending LL indications to all VVIR candidates is unlikely to provide a clearcut survival advantage. Considering the higher costs of LL technology, these data prompt a careful selection of those cases where LL approach does indeed provide an advantage. In addition to the setting of vascular access issues and high bleeding or infectious risk, these may include patients with sufficient life expectancy where lead-related risks may indeed adversely affect prognosis. Based on our patient selection criteria, LL might account for approximately 20% of VVIR pacing recipients. Funding Acknowledgement Type of funding sources: None.

Pathogenesis, Diagnosis, Antimicrobial Therapy, and Management of Infective Endocarditis, and Its Complications.

Infective endocarditis in the adult is life-threatening. Bacterial endocarditis is an inner infection lining the heart muscle (endocardium). The scientific study of the causes of diseases is known as etiology. The agents that cause disease fall into five groups: bacteria, viruses, protozoa, fungi, and helminths (worms). Risk factors are past heart defects, damaged or abnormal heart valves, new valves after surgery, chronic hemodialysis, and immunosuppressed state (chemotherapy, HIV, etc.). Infective endocarditis is categorized into two clinical forms: bacterial acute and subacute endocarditis. Acute bacterial endocarditis is usually caused by staphylococci (staph) and streptococci (strep). And occasionally by listeria and brucella bacterial strains. Invasive medical technology has increased the responsibility of healthcare-associated infective endocarditis (HAIE). Microscopy of the disease is the chronic aggressive cells in the deeper zone of nonspecific, composed of fibrin and platelets covering colonies of bacteria. Tuberculous valvular endocarditis due to mycobacterium tuberculosis is a rare clinical entity. Syphilitic endocarditis is pathologically the cutaneous lesions of secondary syphilis. It is caused by infection with the microorganismTreponema pallidum. Fungal endocarditis is a rare and fatal condition. They are infected with fungi such as Candida albicans, Histoplasma capsulatum, and Aspergillus species. Fatal endocarditis associated with Q fever (query fever). Q fever is a chronic or prolonged disease caused by the rickettsial-like bacillus Coxiella burnetii, a rare form of rickettsia in the endocarditis. Varicella-zoster virus (VZV) infection causes chronic and repeated febrile illness. They are followed by pharyngitis, malaise, and a vesicular rash. Chronic Q fever usually manifests as endocarditis or hepatitis. The therapy given to simplify the complications is antimicrobial therapy. The medicines prescribed are ampicillin, cefazolin, ceftazidime, gentamicin, vancomycin, metronidazole, and tobramycin. High medicinal antibiotics are used to control the spread of infective endocarditis.