Valvular Infective Endocarditis Research Articles

Emerging and Re-Emerging Pathogens in Valvular Infective Endocarditis: A Review.

Infective endocarditis (IE) is a microbial infection of the endocardial surface, most commonly affecting native and prosthetic valves of the heart. The epidemiology and etiology of the disease have evolved significantly over the last decades. With a growing elderly population, the incidence of degenerative valvopathies and the use of prosthetic heart valves have increased, becoming the most important predisposing risk factors. This change in the epidemiology has caused a shift in the underlying microbiology of the disease, with Staphylococci overtaking Streptococci as the main causative pathogens. Other rarer microbes, including Streptococcus agalactiae, Pseudomonas aeruginosa, Coxiella burnetti and Brucella, have also emerged or re-emerged. Valvular IE caused by these pathogens, especially Staphylococcus aureus, is often associated with a severe clinical course, leading to high rates of morbidity and mortality. Therefore, prompt diagnosis and management are crucial. Due to the high virulence of these pathogens and an increased incidence of antimicrobial resistances, surgical valve repair or replacement is often necessary. As the epidemiology and etiology of valvular IE continue to evolve, the diagnostic methods and therapies need to be progressively advanced to ensure satisfactory clinical outcomes.

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-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 PCR of the 16SrRNA gene and sequencing (16SPCR) was evaluated. There were 67/6,692 (1%) episodes of IE caused by Cutibacterium spp., 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 23/50 (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.

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.

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

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.

Multivalvular Endocarditis: A Rare Condition with Poor Prognosis.

Background. Infective endocarditis (IE) is a severe condition. Our aim was to describe the profile and prognosis of patients with multivalvular infective endocarditis (MIE) and compare them to single-valve IE (SIE). Methods. We used a retrospective analysis of the Spanish IE Registry (2008–2020). Results. From 4064 definite cases of valvular IE, 577 (14.2%) had MIE. In patients with MIE, the most common locations were mitral (552, 95.7%) and aortic (550, 95.3%), with mitral-aortic involvement present in 507 patients (87.9%). The most common etiologies were S. viridans (192, 33.3%) and S. aureus (113, 19.6%). MIE involved only native valves in 450 patients (78.0%). Compared with patients with SIE, patients with MIE had a similar age (69 vs. 67 years, respectively, p = 0.27) and similar baseline characteristics, but were more frequently men (67.1% vs. 72.9%, p = 0.005) and had a higher incidence of intracardiac complications (36.2% vs. 50.4%, p < 0.001), heart failure (42.7% vs. 52.9%, p < 0.001), surgical indication (67.7 vs. 85.1%, p < 0.001), surgery (46.3% vs. 56.3%), and in-hospital mortality (26.9% vs. 34.3%, p < 0.001). MIE was an independent predictor of in-hospital mortality (odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1–1.7, p = 0.004) but did not have an independent association with 1-year mortality (OR 1.1, 95% CI 0.9–1.4, p = 0.43). Conclusions. About one-seventh of the valvular IE patients had MIE, mainly due to mitral-aortic involvement. MIE is associated with a poor in-hospital prognosis. An early diagnosis and treatment of IE might avoid its spread to a second valve.

PO-648-08 CONCOMITANT CARDIAC VALVULAR VEGETATION IN PATIENTS WITH CARDIAC IMPLANTABLE ELECTRONIC DEVICE INFECTION IS ASSOCIATED WITH HIGHER ONE YEAR MORTALITY

The emerging data suggest that the incidence of Cardiac Implantable Electronic Devices (CIEDs) infections is on the rise. Infected CIEDs are frequently associated with native or prosthetic valvular infective endocarditis. The effect of concomitant valvular vegetation in the presence of infected CIED is not well characterized.

Incidence, characteristics and outcomes of Infective Endocarditis with low inflammatory markers

Abstract Funding Acknowledgements Type of funding sources: None. Background Bacterial infective endocarditis (IE) is rarely suspected in patients with a low C-reactive protein (CRP) concentration. Aims To address the incidence, characteristics and outcome of left-sided valvular IE with low CRP concentration. Methods This was a retrospective analysis of cases of IE discharged from a tertiary hospital between December 2013 and september 2019. The 10% lowest CRP concentration (&amp;lt;25mg/L) was used to define low CRP concentration. Right-sided cardiac device-related IE, non-bacterial IE, sequelar IE and IE previously treated by antibiotics were excluded. Results Of the 105 patients, 16 (16%; median age 41 [15–76] years) had definite (n = 12) or possible (n = 4) left-sided valvular IE with CRP &amp;lt; 25mg/L (median 14.25 [1.5–24.8] mg/L). The median white blood cell count was 7.7 (4.2–12.5) G/L. The main presentations were heart failure (n = 10; 62%) and stroke (n = 1; 6%). Transthoracic echocardiography (TTE) showed vegetations (n = 12) or isolated valvular regurgitation (n = 4). Overall, nine patients (56%) had severe valvular regurgitation on transoesophageal echocardiography (TOE), and seven patients (43%) underwent cardiac surgery. 68% of patients survived at 1-year follow-up. Bacterial pathogens were documented only in four patients (streptococci, coagulase-negative Staphylococcus, gamella morbillorum) using blood cultures solely , due to lack of disponibility of specific serology / valve culture and/or polymerase chain reaction analysis Conclusions Left-sided valvular IE with limited or no biological syndrome is rare, but is often associated with severe valvular and paravalvular lesions. TOE should be performed in presence of unexplained heart failure, new valvular regurgitation or cardioembolic stroke when TTE is insufficient to rule out endocarditis, even in patients with a low CRP concentration.

Timing of surgery in heart valve infective endocarditis

The prevalence of valvular infective endocarditis (IE) is increasing and is burdened by high mortality and morbidity. Despite the higher risk, the surgical approach is superior to medical therapy alone, and over the years there has been a more aggressive attitude, with earlier indications for surgery. This article aims to review the available literature and the American and European guidelines in order to summarize the most appropriate surgical timing for valvular IE. Although there are discrepancies between the guidelines, an emergent indication (<48 h) should be considered in patients with either native or prosthetic endocarditis with severe regurgitation, outflow obstruction, refractory acute pulmonary edema, cardiogenic shock, or large mobile vegetations (>15-20 mm). Patients with signs of heart failure, persistence of positive cultures for more than 48-72 h despite antibiotic therapy, and in the presence of paravalvular lesions, advanced atrioventricular block and vegetations >10 mm should be operated early (within a few days). If any micro-organisms are isolated, including fungi or multi-resistant organisms in native IE or staphylococci or gram-negative pathogens in prosthesis IE, a more watchful approach (within 2 weeks) should be evaluated. In the presence of large cerebral embolic strokes or cerebral hemorrhage, re-evaluation at 2 and 4 weeks, respectively, is more appropriate. A multidisciplinary approach, especially in the most complex cases, seems to improve the outcome.Key words. Heart valve dysfunction; Heart valve repair; Heart valve replacement; Heart valve surgery; Infective endocarditis; Timing of surgery.

Predictors of mortality in valvular infective endocarditis: A single-center study

Background Valvular infective endocarditis (IE) may occur in association with either native or prosthetic valves, with great risk of mortality and morbidity. Surgical management is an essential part of the therapeutic process in these patients. Objectives This study aims at evaluation of early outcomes of surgically treated patients with native or prosthetic IE together with determining predictors of mortality. Patients and methods Outcomes of 60 patients who underwent surgery for native or prosthetic valve endocarditis at National Heart Institute during a 3-year period (April 2016 to March 2019) were studied prospectively. Preoperative, intraoperative, and postoperative data were tested as possible predictors for mortality. All patients were followed for at least 6 months after surgery. Results The hospital mortality rate was 11 (18.3%) patients, and total mortality rate after 6-month follow-up was 17 (28.3%) patients. Native valve endocarditis was present in 36 (60.0%) patients and prosthetic valve endocarditis in 24 (40.0%) patients. The commonest involved valve was mitral valve in 19 (31.7%) followed by aortic valve in 14 (23.3%). The commonest isolated organisms were Staphylococcus spp., which was found in 19 (31.6%) patients, followed by Streptococcus spp. and Gram negative bacteria, which were found in nine (15.0%) patients each. Mean Euro score II was 6.21 ± 2.54 in the surviving group. Duration of bypass time was 144.75 ± 35.81 min in dead patients and 104.56 ± 20.43 min in the surviving patients. Congestive heart failure, embolization, and periannular extension of infection were the most powerful predictors of in-hospital mortality. Periannular extension of infection was the most powerful predictor of 6-month mortality. Conclusion Surgery for IE is risky, especially in redo cases. Extensive infection carried the worst prognosis. Euro score II is a reliable indicator for hospital and early mortality. Valve repair can be performed in selected cases.

Cardiovascular implantable electronic device infections due to enterococcal species: Clinical features, management, and outcomes.

Enterococcal cardiovascular implantable electronic device (CIED) infections are not well characterized. Data from the Multicenter Electrophysiologic Device Infection Cohort, a prospective study of CIED infections, were used for descriptive analysis of adults with enterococcal CIED infections. Of 433 patients, 21 (4.8%) had enterococcal CIED infection. Median age was 71 years. Twelve patients (57%) had permanent pacemakers, five (24%) implantable cardioverter defibrillators, and four (19%) biventricular devices. Median time from last procedure to infection was 570 days. CIED-related bloodstream infections occurred in three patients (14%) and 18 (86%) had infective endocarditis (IE), 14 (78%) of which were definite by the modified Duke criteria. IE cases were classified as follows: valvular IE, four; lead IE, eight; both valve and lead IE, six. Vegetations were demonstrated by transesophageal echocardiography in 17 patients (81%). Blood cultures were positive in 19/19 patients with confirmed results. The most common antimicrobial regimen was penicillin plus an aminoglycoside (33%). Antibiotics were given for a median of 43 days. Only 14 patients (67%) underwent device removal. There was one death during the index hospitalization with four additional deaths within 6 months (overall mortality 24%). There were no relapses. Enterococci caused 4.8% of CIED infections in our cohort. Based on the late onset after device placement or manipulation, most infections were likely hematogenous in origin. IE was the most common infection syndrome. Only 67% of patients underwent device removal. At 6 months follow-up, no CIED infection relapses had occurred, but overall mortality was 24%.

Enterobacter Cloacae Device Endocarditis: Case Report, Scoping Study, and Guidelines Review.

While traditionally an infection of the endocardial surface of heart valves, infective endocarditis (IE), can atypically present as infection of cardiac implantable electronic devices (CIED), including permanent pacemakers (PPM) or automatic implantable cardioverter-defibrillators (AICD). CIED endocarditis, similar to valvular IE, is generally caused by Gram-positive organisms such as Staphylococcus spp., most frequently S. Auerus, but is rarely caused by gram-negative bacteria, both HACEK and non-HACEK species. We present the case of Enterobacter cloacae CIED endocarditis. We also present a scoping study of previous case reports and case series highlighting the risk factors, surgical interventions, and mortality outcomes associated with E. Cloacae endocarditis. We also discuss the current guidelines and recommendations on antibiotic therapies for non-HACEK Gram-negative endocarditis and surgical management of infected CIED extraction and replacement.

Infective endocarditis without biological inflammatory syndrome: Description of a particular entity

Bacterial infective endocarditis (IE) is rarely suspected in patients with a low C-reactive protein (CRP) concentration. To address the incidence, characteristics and outcome of left-sided valvular IE with low CRP concentration. This was a retrospective analysis of cases of IE discharged from our institution between January 2009 and May 2017. The 10% lowest CRP concentration (<20mg/L) was used to define low CRP concentration. Right-sided cardiac device-related IE, non-bacterial IE, sequelar IE and IE previously treated by antibiotics were excluded. Of the 469 patients, 13 (2.8%; median age 68 [61-76] years) had definite (n=8) or possible (n=5) left-sided valvular IE with CRP<20mg/L (median 9.3 [4.7-14.2] mg/L). The median white blood cell count was 6.3 (5.3-7.5) G/L.The main presentations were heart failure (n=7; 54%) and stroke (n=3; 23%). Transthoracic echocardiography (TTE) showed vegetations (n=5) or isolated valvular regurgitation (n=4). Overall, eight patients (62%) had severe valvular lesions on transoesophageal echocardiography (TOE), and nine patients (69%) underwent cardiac surgery. All patients survived at 1-year follow-up. Bacterial pathogens were documented in eight patients (streptococci, coagulase-negative Staphylococcus, Corynebacteriumjeikeium, HACEK group, Coxiella burnetii, Bartonella henselae) using blood cultures, serology or valve culture and/or polymerase chain reaction analysis. Left-sided valvular IE with limited or no biological syndrome is rare, but is often associated with severe valvular and paravalvular lesions. TOE should be performed in presence of unexplained heart failure, new valvular regurgitation or cardioembolic stroke when TTE is insufficient to rule out endocarditis, even in patients with a low CRP concentration.

Simultaneous Enterococcus faecalis Mitral Valve Endocarditis, Mycotic Aortoiliac, and Intracranial Aneurysms: A Surgical Dilemma

Mycotic aortic aneurysms comprise <5% of all aortic aneurysms, but have a high risk of rupture if not treated urgently. Concomitant valvular infective endocarditis poses additional therapeutic challenges in relation to staged repair. Current surgical recommendations for mycotic aortic aneurysms involve urgent repair, due to the high risk of rupture and associated mortality. The presence of infective endocarditis necessitates early valve replacement to avoid further systemic emboli or seeding of vascular grafts; however, the risk of heparin loading during cardiopulmonary bypass on a friable aorta poses significant risks. Staged repair with an initial, temporary exclusion graft can reduce these risks but is poorly studied in the literature. This study reported a case of a 60-year-old male patient who presented with Enterococcus faecalis native mitral valve infective endocarditis with associated mycotic aortoiliac aneurysms and who successfully underwent staged repair.

1085. Enterococcal Cardiac Implantable Electronic Device (CIED) Infections: Clinical Features and Outcomes

BackgroundUnlike enterococcal native and prosthetic valve infective endocarditis (IE), enterococcal CIED infections are not well described.MethodsData from the Multicenter Electrophysiologic Device Infection Collaboration (MEDIC), a prospective, observational, multinational cohort study of CIED infections, were used to provide a descriptive analysis of adult patients with CIED infections due to enterococcal species.ResultsOf 433 patients, 21 (4.8%) were diagnosed with enterococcal CIED infection. Specific data on enterococcal species and antimicrobial susceptibilities were not recorded. The mean age was 70.8 years. No patient had previous CIED infection. Twelve patients (57%) had permanent pacemakers, 5 (24%) had implantable cardioverter defibrillators, and 4 (19%) had biventricular devices. Among the 21 infections, 3 (14%) were categorized as CIED-related bloodstream infections and 18 (86%) as IE; no patient had isolated pocket infection. Of the IE cases, four were valvular IE, eight were lead IE, and six were both. Fourteen cases of IE (78%) were definite by the modified Duke criteria. Median time from last device procedure to infection was 510 days (range 37–2,952 days). The most common presenting symptom was fever (48%); five patients (24%) exhibited local signs of pocket infection. All 21 patients underwent TEE with vegetations demonstrated in 17 (81%). Blood cultures grew enterococci from all patients. The most common antimicrobial regimen was a penicillin plus aminoglycoside (38%); two patients (9.5%) received ampicillin + ceftriaxone. Antibiotics were given for a median of 43 days. Only 14 patients (67%) had complete device removal; the seven patients retaining their device were judged to be at high risk for extraction. There was one death during the index hospital stay with four additional patients dying over the 6 months after therapy (overall mortality 24%); two of the seven patients retaining their CIED died.ConclusionEnterococci caused 4.8% of all CIED infections in our cohort. Most infections appeared to be hematogenous in origin with late onset. IE was the most common infectious syndrome. A penicillin plus aminoglycoside, given for 6 weeks, was the most frequent therapy. Only 67% of patients underwent device removal. At 6 months follow-up, no relapses had occurred but overall mortality was 24%.Disclosures J. E. Peacock Jr., Pfizer, Inc.: Shareholder, Owns common stock in Pfizer which was inherited and held in a trust. M. R. Sohail, TyRx Inc.: Investigator, Research support. Medtronic Inc.: Investigator, Research support. Medtronic Inc.: Consultant, Speaker honorarium. Spectranetics: Consultant, Speaker honorarium. Boston Scientific Corp: Consultant, Speaker honorarium. L. M. Baddour, UpToDate: Collaborator, Royalty payment. J. M. Miro, Abbvie: Consultant and Grant Investigator, Consulting honoraria and Research grant. Bristol-Myers Squibb: Consultant and Grant Investigator, Consulting honoraria and Research grant. Genentech: Consultant and Grant Investigator, Consulting honoraria and Research grant. Medtronic: Consultant and Grant Investigator, Consulting honoraria and Research grant. Novartis: Consultant and Grant Investigator, Consulting honoraria and Research grant. Gilead Sciences: Consultant and Grant Investigator, Consulting honoraria and Research grant. Pfizer: Consultant and Grant Investigator, Consulting honoraria and Research grant. ViiV Healthcare: Consultant and Grant Investigator, Consulting honoraria and Research grant. A. J. Greenspon, Medtronic: Consultant, Speaker honorarium. Boston Scientific: Consultant, Speaker honorarium. St. Jude: Consultant, Speaker honorarium. R. G. Carrillo, St. Jude Medical Group: Speaker’s Bureau, Research support. Spectranetics: Consultant, Speaker honorarium. Sorin Group: Speaker’s Bureau, None. Boston Scientific Corp: Speaker’s Bureau, None. D. Z. Uslan, Medtronic: Investigator, Research support. Boston Scientific: Consultant, Speaker honorarium.

Infective Endocarditis: how many ultrasonography studies are necessary to reach the diagnosis? A real world scenario (2008-2017)

Background: The central role of echocardiography in the diagnosis, prognosis, and management of infective endocarditis (IE) has been clearly established. Both echocardiograpy and blood cultures are the major criteria to reach the diagnosis of IE. Although 2D transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have complementary roles, TEE has more sensitivity and specificity especially in the presence of intracardiac device. Sometimes, however, in spite of a high clinical suspicion, the first study that is carried out does not contribute with elements that confirm this suspicion and many expert and guidelines suggest to repeat the study in a relatively short time. To analize the role of repeated echoes in the diagnosis of definite IE. Methods & Materials: Retrospective, observational study of consecutives cases of Definite IE according to modified Duke Criteria, in adults patients admitted in a single cardiovascular referral center. Results: From January/2008 to June/2017, 148 definite EI (43 native valve, 72 prosthetic valve, 33 pacemaker-associated IE) were included. All ptes underwent TTE and TEE. The first echoe was made a median of 2 d since the hospitalization day (range = 0-13 d; SD +/- 2) and showed images suggesting IE in 106/148 pts (71.6%). A 2nd echoe was performed in 18 pts in a median time of 7 days and showed images not seen in the previous echoe in 11/18 pts (61%). Considering only “valvular IE” (n = 115) the first echo was “positive” for IE in 76.5% and 86% in the 2nd echoe: native valve IE 81.4% vs 83.7%; PVIE 73.6% vs 87.5% (early PVIE - n: 32 - 75% vs 90%) respectively. Conclusion: Ultrasonography is unequivocally the mainstay of diagnostic imaging in IE. Repeat the study in the case of a high clinical suspicion could notably increase the possibility of achieving the diagnosis of IE, especially when intracardiac device (e.g: prosthetic valves) are probably involved.

Predictors of in-hospital mortality in surgically treated valvular infective endocarditis cases at National Heart Institute, Egypt

BackgroundThe aim of this study was to review the surgical experience in the cardiothoracic surgical department, National Heart Institute (NHI), Egypt regarding patients with native or prosthetic valve endocarditis and determining predictors of mortality. MethodsA prospective study of fifty consecutive patients diagnosed with definite infective endocarditis (IE) and underwent cardiac surgery from September 2012 till September 2014 were included. We tested preoperative, intraoperative, and postoperative data as potential predictors of mortality. ResultsRheumatic heart disease was the most common underlying cardiac disease (n = 27, 54%). Native valve endocarditis was present in 37 (74%) and prosthetic valve endocarditis in 13 (26%). Mean EuroSCORE II was 5.71%. The in-hospital mortality was 20%. Congestive heart failure (P = 0.014), embolization (P = 0.011), and periannular extension of infection (P = 0.029) were independent predictors of in-hospital mortality. According to the ROC curve, EuroSCORE II > 5.93% was associated with the best predictive value for in-hospital mortality (AUC: 0.813). In the group of patients selected for valve repair strategy, only one mortality (11%) was recorded and no recurrence occurred. ConclusionsSurgery for IE continues to be challenging. EuroSCORE II has a good discrimination ability to predict in-hospital mortality in IE surgery. Satisfactory results can be obtained with valve repair in IE.

Surgical Treatment of Valvular Infective Endocarditis Complicated by An Abscess: A Single Center’s Experience

Objectives: To examine the surgical treatment and mortality rate of valvular infective endocarditis complicated by an abscess in patients at a major tertiary care center. Background: Infective endocarditis (IE) involving a heart valve is fatal if left untreated. The appearance of a comorbid abscess impacts the choice of treatment and surgical technique and, in some instances, may present unique technical challenges. Methods: Departmental data from all patients who underwent surgery for IE at a single major tertiary care center from July 2007 to January 2016 were retrospectively screened for the presence of an intracardiac abscess. Patients with at least one confirmed abscess were examined further with respect to the surgical procedures completed and 30-day mortality rate. Results: Over the almost nine years of data collection, we identified 14 patients (9 males, 5 females) with at least one confirmed cardiac abscess. Patients ranged in age from 28 to 77 years old (mean 57.8 ± 14 years). Various surgical procedures were performed, including aortic or/and mitral valve replacement, mitral or/and tricuspid valve repair, and a freestyle prosthetic valve implant in the pulmonary position. In two patients, surgery was extended to include the ascending aorta; while two patients underwent coronary artery bypass grafting. A patch technique was adopted whenever necessary. Overall, 12 patients survived, while one died from septic shock and another from pneumonia. Conclusions: An abscess is a serious complication of valvular infective endocarditis that can appreciably increase the complexity of surgical intervention. In our experience, however, this seemed not to directly affect the 30-day mortality-rate, with both deaths ascribed to disseminated infection.

A Meta-Analysis of Early versus Delayed Surgery for Valvular Infective Endocarditis Complicated by Embolic Ischemic Stroke

A Meta-Analysis of Early versus Delayed Surgery for Valvular Infective Endocarditis Complicated by Embolic Ischemic Stroke

Aorto-left atrial fistula: Rare cause of acute cardiac failure in a previously healthy individual

Complications of valvular infective endocarditis involving the peri-annular region puts the patient at a significantly high risk of adverse outcomes including heart failure and death. The “mitral–aortic intervalvular fibrosa” is relatively avascular and offers little resistance to the spread of abscesses, aneurysm, and fistula formation. Aorto-cavitary fistulous tract formation in the setting of native valve infective endocarditis is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscesses. Thus, a high index of suspicion is needed for rapid and accurate diagnosis, which can guide further management. A transesophageal echocardiogram is the preferred modality of investigation in such cases. Staphylococci are reported to be the most common pathogen involved. In addition to early antibiotic therapy, prompt surgical intervention might save lives in these scenarios.