Vegetation Size Research Articles

Long-term impact of persistent vegetations at 6 month followup after treatment of infective endocarditis: a substudy of the Partial Oral vs Intravenous Antibiotic Treatment of Endocarditis (POET) tria

Abstract Background Our knowledge of changes in vegetation size throughout the course of infective endocarditis (IE) and the impact of persistent vegetations on mortality or embolization after completed antibiotic treatment is sparse. No study has previously investigated the prevalence or clinical impact of persistent vegetations on transthoracic echocardiography (TTE) at 6-months follow-up after ended IE treatment. Purpose To investigate the association between persistent vegetations at the 6-months TTE after treatment for IE and long-term prognosis as assessed in the POET trial. Methods The POET trial was a nationwide, multicenter RCT, randomizing 400 patients to either partial oral or intravenous (IV) antibiotic treatment of left-sided IE, after initial stabilization of infection using conventional IV therapy. A persistent vegetation was defined as a vegetation seen on 6-months follow-up TTE (4–7 months) after ended antibiotic treatment for IE. In the POET trial, primary outcome was defined as 1) all-cause mortality, 2) unplanned cardiac surgery, 3) embolic events or 4) relapse of bacteremia, in the 5-year follow-up period. Patients without TTE due to death or lack of available TTE were excluded. Results Out of 400 patients, 20 were excluded due to death during 6-months follow-up, and 201 were excluded due to unavailable TTE, leaving 179 TTEs for analysis. At 6-months follow-up, a persistent vegetation was seen in 30 patients (16.7%, 21 males (70%), mean age 69.6 years (SD 7.7)) (Table 1). Seventeen patients (56.7%) had a persistent vegetation on the aortic valve and 13 patients (43.3%) on the mitral valve. More patients without a persistent vegetation had undergone initial surgical treatment of IE than those with a vegetation (57.7 vs 23.3%, p=0.001). In all surgically treated patients with persistent vegetation at 6-months follow-up, the vegetation was found on another valve than the operated valve. The composite primary outcome from 6-months follow-up and until 5-year follow-up occurred in 8 patients (26.7%) with a persistent vegetation, compared to 38 patients (25.5%) (p=1.00) without. (Table 2) In patients randomized for peroral treatment, no significant difference in prevalence of persistent vegetation was found (15 patients (50%) with persistent vegetations vs. 74 patients (49.7%) without, p=1.00). Conclusion The occurrence of persistent vegetations at 6 months follow-up was 16.7%. There was no association between persistent vegetations at 6-months follow-up and the occurrence of the primary outcome after 5 years follow-up, suggesting that the risk associated with residual vegetations after end of antibiotic treatment is negligible after 6-months. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

The role of imaging in infective endocarditis.

Infective endocarditis (IE) poses a large diagnostic and therapeutical challenge. An early diagnosis is necessary for a positive outcome. Echocardiography is initial diagnostic method when there is a possibility of IE presence. TTE and TEE are useful in detection, accurate localisation and estimation of vegetation size, and also in detection of paravalvular spreading of infection. In certain situations, there is a need for usage of complementary methods like CCT and nuclear techniques. This article will outline advantages and limitations of certain diagnostic methods in diagnosis of IE.

A 10-year retrospective analysis of the clinical profile and outcomes of infective endocarditis at a tertiary hospital in KwaZulu-Natal, South Africa.

To examine the clinical profile and treatment outcomes of infective endocarditis (IE) at a tertiary hospital in KwaZulu-Natal. A 10-year retrospective analysis was conducted on cases of definite IE (modified Duke criteria). Ninety-seven subjects (HIV infected, n = 12) satisfied the study criteria (mean age 29.7 ± 15.6 years, M:F 1.4:1). Underlying rheumatic heart disease was present in 84.5% and severe dyspnoea in 67.0% of cases. Staphylococcus aureus was the commonest pathogen isolated (18.6%). Heart failure was present in 61.9% and vegetations were identified in 85 (87.6%) subjects, resulting in 41 (42.3%) embolic events. The clinical profile and outcomes were similar in the HIV-positive and -negative patients. Surgery was performed in 73 subjects (surgical mortality rate 9.5%, total mortality rate 26.4%). Multivariate analysis identified acute-onset IE [odds ratio (OR) 251.46, 95% confidence interval (CI) 1.18-5343.63, p = 0.043], vegetation size > 15 mm (OR 222.60, 95% CI 1.04-4730.34, p = 0.043) and medical management only (OR 20.89, 95% CI 2.12-200.06, p = 0.037) as predictors for increased in-hospital mortality. IE affects young people with underlying rheumatic heart disease and is associated with high morbi-mortality attributable to advanced disease at presentation and to haemodynamic failure resulting from valve destruction due to acute onset of aggressive infection.

Risk factors for neurological complications in left-sided infective endocarditis

Background and purposeNeurological complications following infective endocarditis (IE) directly contribute to long-term morbidity. We examined the risk factors for different neurological complications of left-sided IE. MethodsUsing a database of consecutive adults admitted to a health system with left-sided IE from 2015 to 2019, the frequency of cerebral infarcts, intraparenchymal hemorrhage, cerebral microbleeds (CMB), mycotic aneurysm, and encephalopathy was determined. Variables with significant differences comparing each neurological complication (p < 0.1) were entered into regression models along with age to determine predictors. Results211 patients with mean age 54 (±18) years, and 69 (33%) females were included. Infarcts were found in 118 (56%) patients, intraparenchymal hemorrhage was found in 17 (8%) patients, CMB were found in 58 (27%) patients, mycotic aneurysms were found in 22 (10%) patients, and encephalopathy occurred in 16 (8%) patients. In multivariable models, vegetation size ≥15 mm was associated with a higher risk of infarcts (aOR 2.26, 95% CI (1.12–4.57)), and the presence of a mycotic aneurysm was a risk factor for intraparenchymal hemorrhage (aOR 18.79, 95% CI (3.97–88.97)). Prosthetic valves (aOR 2.89, 95% CI (1.11–7.54)) and Staphylococcus aureus infection (aOR 3.50, 95% CI (1.08–11.36)) were associated with CMB. No risk factors emerged as predictors of encephalopathy. ConclusionsLarge vegetation size is associated with stroke in patients with IE. Mycotic aneurysms are found at a higher frequency in young patients and are the primary cause of intraparenchymal hemorrhage. CMB may be related to prosthetic valves and Staphylococcus aureus infection.

Habitat preferences of young-of-year spotted gar (Lepisosteus oculatus) in Rondeau Bay, Lake Erie

The young-of-year (YOY) habitat of many fishes listed under the Species at Risk Act (SARA) is poorly described, yet identifying critical habitat is essential to ensure species recovery. Past research on the Endangered spotted gar ( Lepisosteus oculatus Winchell, 1864) in Canada has focused on the habitat use of adults and juveniles, but little is known about the occurrence and habitat use of YOY. Dip net and aquatic habitat sampling were performed in nearshore (lakefront, agricultural drain), mid-channel (agricultural drain), and offshore sites within Rondeau Bay to determine the fine-scale habitat occupancy patterns of age-0 spotted gar. Habitat preference analysis indicated YOY spotted gar strongly preferred shallow (0.5–1.0 m), vegetated, nearshore (lakefront and agricultural drain) habitat and avoided offshore habitat. An association between submerged aquatic vegetation (SAV) and fish size was also found, as dependence on SAV diminished as total length increased. Our study represents the first capture and assessment of habitat associations of early-stage YOY spotted gar in Canada. Given our findings, management efforts should focus on protecting the vegetated nearshore habitat in Rondeau Bay and other occupied locations in Lake Erie to ensure the long-term persistence of spotted gar in Canada.

Lead-related infective endocarditis with vegetations: Prevalence and impact of pulmonary embolism in patients undergoing transvenous lead extraction.

The prevalence and impact of pulmonary embolism (PE) in patients with lead-related infective endocarditis undergoing transvenous lead extraction (TLE) are unknown. Twenty-five consecutive patients with vegetations ≥10 mm at transoesophageal echocardiography were prospectively studied. Contrast-enhanced chest computed tomography (CT) was performed before (pre-TLE) and after (post-TLE) the lead extraction procedure. Pre-TLE CT identified 18 patients (72%) with subclinical PE. The size of vegetations in patients with PE did not differ significantly from those without (median 20.0 mm [interquartile range: 13.0-30.0] vs. 14.0 mm [6.0-18.0], p = 0.116). Complete TLE success was achieved in all patients with 3 (2-3) leads extracted per procedure. There were no postprocedure complications related to the presence of PE and no differences in terms of fluoroscopy time and need for advanced tools.In the group of positive pre-TLE CT, post-TLE scan confirmed the presence of silent PE in 14 patients (78%). There were no patients with new PE formation. Large vegetations (≥20 mm) tended to increase the risk of post-TLE subclinical PE (odds ratio 5.99 [95% confidence interval (CI): 0.93-38.6], p = 0.059).During a median 19.4 months follow-up, no re-infection of the implanted system was reported. Survival rates in patients with and without post-TLE PE were similar (hazard ratio: 1.11 [95% CI: 0.18-6.67], p = 0.909). Subclinical PE detected by CT was common in patients undergoing TLE with lead-related infective endocarditis and vegetations but was not associated with the complexity of the procedure or adverse outcomes. TLE procedure seems safe and feasible even in patients with large vegetations.

Outcomes of Mitral Valve Repair in Children With Infective Endocarditis: A Single-Center Experience

Mitral valve infective endocarditis (IE) in children is rare, and there are few reports on the outcomes of surgery in these patients. This study investigated the long-term outcomes of mitral valve repair in children with IE. Data were retrospectively obtained from medical records and correspondence. Univariable regression analyses were performed and outcomes including survival and freedom from reoperation were analyzed using the Kaplan-Meier method. Surgery for native mitral valve IE was performed in 39 patients between 1987 and 2020. Of these, 92.3% (36/39) of patients underwent mitral valve repair, while 7.7% (3/39) required replacement. Median age was 8 years. Preoperatively, 80.5% (29/36) of patients had moderate or greater mitral regurgitation. Congenital heart disease was present in 38.9% (14/36), while 11.1% (4/36) had rheumatic heart disease and 25.0% (9/36) had prior cardiac surgery. Postoperatively, only 1 patient (2.8%, 1/36) had moderate or greater residual mitral regurgitation. There were 2 early deaths (5.6%, 2/36), with survival being 94.1% (95%CI, 78.5-98.5) at 15 years. At 10 years, freedom from reoperation was 62.9% (95%CI, 41.0-78.5) while freedom from mitral valve replacement was 80.2% (95%CI, 55.5-92.3). Larger vegetation size was a risk factor for embolic events both pre- and postoperatively (OR, 1.15, P=0.02). Mitral valve repair is feasible in the majority of children requiring surgery for mitral valve IE. Survival is excellent, and at 10 years, approximately two-thirds of patients are free from mitral reoperation, and 80% are free from replacement. Larger vegetation size is associated with an increased risk of embolic events.

Characteristics, management, and outcomes of patients with left-sided infective endocarditis complicated by heart failure: a substudy of the ESC-EORP EURO-ENDO (European infective endocarditis) registry.

AimsTo evaluate the current management and survival of patients with left‐sided infective endocarditis (IE) complicated by congestive heart failure (CHF) in the ESC‐EORP European Endocarditis (EURO‐ENDO) registry.Methods and resultsAmong the 3116 patients enrolled in this prospective registry, 2449 (mean age: 60 years, 69% male) with left‐sided (native or prosthetic) IE were included in this study. Patients with CHF (n = 698, 28.5%) were older, with more comorbidity and more severe valvular damage (mitro‐aortic involvement, vegetations >10 mm and severe regurgitation/new prosthesis dehiscence) than those without CHF (all p ≤ 0.019). Patients with CHF experienced higher 30‐day and 1‐year mortality than those without (20.5% vs. 9.0% and 36.1% vs. 19.3%, respectively) and CHF remained strongly associated with 30‐day (odds ratio[OR] 2.37, 95% confidence interval [CI] [1.73–3.24; p < 0.001) and 1‐year mortality (hazard ratio [HR] 1.69, 95% CI 1.39–2.05; p < 0.001) after adjustment for established outcome predictors, including early surgery, or after propensity matching for age, sex, and comorbidity (n = 618 [88.5%] for each group, both p < 0.001). Early surgery, performed on 49% of these patients with IE complicated by CHF, remained associated with a substantial reduction in 30‐day mortality following multivariable analysis, after adjustment for age, sex, Charlson comorbidity index, cerebrovascular accident, Staphylococcus aureus IE, streptococcal IE, uncontrolled infection, vegetation size >10 mm, severe valvular regurgitation and/or new prosthetic dehiscence, perivalvular complication, and prosthetic IE (OR 0.22, 95% CI 0.12–0.38; p < 0.001) and in 1‐year mortality (HR 0.29, 95% CI 0.20–0.41; p < 0.001).ConclusionCongestive heart failure is common in left‐sided IE and is associated with older age, greater comorbidity, more advanced lesions, and markedly higher 30‐day and 1‐year mortality. Early surgery is strongly associated with lower mortality but is performed on only approximately half of patients with CHF, mainly because of a surgical risk considered prohibitive.

Flow behaviour in a multi‐layered vegetated floodplain region of a compound channel

AbstractRiparian vegetation plays a crucial role in determining the flow behaviour in the channel. The effect of flow on the slope and main channel varies based on the size, type, and density of floodplain vegetation in a compound channel. Though real field vegetation distribution is non‐uniform, most studies mainly concentrate on uniformly distributed vegetation with fixed vegetation height. This paper attempts to address this issue through laboratory studies as it was not explored properly. Flow properties like velocity, Reynolds shear stress, turbulence intensities, and turbulent kinetic energy behave differently in heterogeneous vegetated channel compared with the homogeneous vegetated channel. These flow properties in the slopes and main channel section are more pronounced for uniformly distributed vegetation than non‐uniform distribution. The multi‐layered/varying vegetation height showed higher velocity, turbulent intensity, and turbulent kinetic energy than single‐layered/constant vegetation height on slopes and main channel sections. Integral scales (Taylor and Euler) analysis showed greater magnitude for uniform multi‐layered vegetation than non‐uniform multi‐layered vegetation. Further, the study of octant analysis reveals that internal outward and internal inward interaction events dominate the slope floodplain interaction section, which is not seen in no‐vegetation cases. These studies give a better perspective to understand flow in heterogenous vegetation and move closer to real field scenarios.

Echocardiographic features of infective endocarditis in South Africa: A prospective cohort study

Background. Historically, infective endocarditis (IE) in South Africa (SA) was associated with the viridans group of streptococci affecting patients with underlying rheumatic heart disease (RHD). A changing IE bacteriological profile raises the question of whether the profile of underlying valvular abnormality has changed. Objectives. To investigate the prevalence of underlying structural valve abnormalities and their aetiologies associated with IE in SA, and describe the typical imaging findings. Methods. The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and April 2021. Patients underwent detailed transthoracic and transoesophageal echocardiography to assess their underlying cardiac and valvular structure. Results. Among 71 patients included, a predisposing endocardial abnormality was detected in 49.3%, with RHD the most common single identifiable aetiology (16.9%). The in-hospital mortality rate was similar in patients with and without a predisposing endocardial abnormality (20% v. 16.7%; p=0.72), as was the rate of embolic events (20% v. 27.2%; p=0.58). Significantly more patients with a predisposing endocardial abnormality had an indication for surgery (94.3% v. 69.4%; p&lt;0.01). The viridans group of streptococci was more prevalent in patients with a predisposing endocardial abnormality (25.7% v. 2.7%; p&lt;0.01). Left-sided linear vegetation size &gt;10 mm was associated with an increased risk of in-hospital mortality (24% v. 5%; p=0.05). Conclusion. We observed a marked decrease in the prevalence of RHD in this cohort of patients with IE. The viridans group of streptococci was an uncommon cause of IE in patients with no predisposing endocardial abnormality detected. The presence of a predisposing endocardial abnormality was not associated with an increased risk of in-hospital mortality or embolic events. Linear vegetation length &gt;10 mm was associated with an increased risk of in-hospital mortality in patients with left-sided IE.

Unexpected isolated native pulmonary valve endocarditis; really benign as thought?

Isolated pulmonary valve endocarditis is extremely rare, accounting for <2% of cases. Major predisposing factors are intravenous drug use, implanted cardiac devices, congenital heart diseases, and central venous catheters. Most patients respond well to appropriate antibiotherapy. We report a case with an isolated native pulmonary valve endocarditis due to methicillin-resistant staphylococcus-aureus infection which developed after a tooth abscess in a previously healthy non-drug user young male. After one week antibiotherapy, surgery was required due to acute severe pulmonary insufficiency and right heart-failure. After the operation, he had a multi-organ failure despite veno-arterial extracorporeal membrane oxygenation, antibiotherapy, and other supportive treatments, therefore the case concluded with mortality. Our case showed that pulmonary valve endocarditis may occur in patients without risk factors in case of portal of entry for bacteremia and it may carry worse prognosis than previously known. Virulence of the microorganism and vegetation size are the major predictors of prognosis. Pulmonary valve endocarditis should be kept in mind even in patients without any known risk factors.

Optimal empirical antimicrobial therapy in infective endocarditis.

The case report of left-sided infective endocarditis (IE) in intravenous drug use (IDU) reminds the importance of recognizing peripheral stigmata of IE with subsequent immediate aggressive management.1 However, the management of this patient, including inappropriate the choice of empirical antibiotics and no consideration of valve surgery (given large size of vegetation and systemic embolization), does not seem appropriate. The current literature recommends empirical antimicrobial coverage of methicillin-resistant Staphylococcus aureus (MRSA) and potentially antibiotic-resistant Gram-negative bacilli (including Pseudomonas spp.) in IDU-IE.2–4 A combination of vancomycin plus gentamicin or cefepime covers these bacteria and other potential agents pending culture results.2,3 MRSA, the commonest cause of both right- and left-sided IDU-IE, was not covered in the index case report before the blood cultures were obtained.2–5 Our large IE study, published from the same center (Postgraduate Institute of Medical Education and Research, Chandigarh), also supports the combination of vancomycin and gentamicin for empirical treatment in IDU-IE.6

Surgical procedure versus medical treatment for infective endocarditis associated to mortality in Mexican population.

Background:Early surgical procedures on patients with infective endocarditis (IE) have shown a clearly benefit to reduce embolization at the central nervous system. We conducted a retrospective cohort in Mexican population to evaluate mortality and clinical outcomes in patients with IE with or without surgical intervention.Objectives:Our aim was to evaluate factors associated with mortality in patients with IE and compare both groups with and without a surgical intervention.Methods:We evaluated a retrospective cohort of patients who had been diagnosed with IE according to the Duke’s criteria at our Institution in SLP, Mexico, from January 2001 to September 2016. We compared the risk factors associated to mortality of patients with or without surgery. Our primary outcome was mortality within 6 months of follow-up after the diagnosis.Results:We included 105 patients, 51 (48.6%) were men, median age 46 [Q1 30, Q3 59] years, 36 patients (34.3%) received surgical treatment (STG), and 69 (65.7%) only medical treatment (MTG) group; 41 patients (39%) died during the study period; in the surgery group eight patients died (22%); and 33 in the MT group (47%) p = 0.049. Adjusted for APACHE II, surgery, creatinine levels and the size of vegetation, the surgery group had lower mortality than patients on MTG (HR 0.36, p = 0.047).Conclusion:As previously described in the literature, patients who underwent surgery had lower mortality than the patients who only received medical treatment; however, the Mexican population is different to other populations group, due to higher risk of diabetes mellitus (28%) versus (10%) in global risk of DM in the world and its complications and other chronic diseases as arterial systemic hypertension. Thus, surgical treatment must be elected as goal standard treatment in patient’s whit IE and presence of vegetation.

A Retrospective Study on the Predictors of Outcome in Patients with Infective Endocarditis

Background Infective endocarditis (IE) is associated with significant mortality and morbidity. This study aims to update the epidemiology of IE and to identify predictors of adverse outcome in the Chinese population in Hong Kong. Methods This was a single-centre retrospective study of patients diagnosed with IE in Princess Margaret Hospital in Hong Kong during 2002-2016. Primary outcome was defined as in-hospital mortality. Secondary outcomes included 1-year mortality, valvular surgical intervention, heart failure, stroke and systemic embolization. Results In total, 196 patients with definite or possible IE were included in the study. The incidence of IE was 2.26 per 100,000 person-years and had remained stable. Health care-associated IE (HCAIE) accounted for 32% of cases, with an increasing trend. Staphylococcus aureus was the most frequently isolated organism in the overall study population (37.8%) and among intravenous drug users (85.2%). In-hospital mortality remained high (29.1%) and was independently associated with higher Charlson Comorbidity Index (OR 1.24, p=0.001), heart failure (OR 5.65, p Discussion This study showed that the incidence of IE remained stable during 2002-2016. There was an increasing proportion of HCAIE and Staphylococcus aureus has become the most common causative organism. IE was associated with high mortality and morbidity. Independent predictors for in-hospital mortality were patient’s medical comorbidity, large vegetation size and heart failure, while infection by viridans group streptococci was associated with reduced risk.

Successful Debulking of Tricuspid Valve Vegetation Using Suction Filtration and Veno-Venous Bypass

Tricuspid valve endocarditis with recurrent septic pulmonary emboli is an indication for surgery. In this report, we present a case of right-sided infective endocarditis (RSIE) in a female patient with a history of intravenous drug use (IVDU). The patient was admitted with multiple chief complaints of fatigue, chills, fever, cough, chest pain, and shortness of breath. She was found to have a large 1.8 cm (W) x 2.4 cm (L) mobile tricuspid valve vegetation on transthoracic echocardiogram (TTE). Despite being on appropriate antibiotics, the patient failed to improve clinically. Cardiothoracic surgery (CTS) evaluated the patient for surgical management of infective endocarditis (IE) given the size of vegetation, persistent bacteremia, and clinical deterioration. However, the risk/benefit ratio for open-heart surgery was high, given the history of active IVDU and hemodynamic instability. The patient underwent percutaneous extraction of the vegetation using suction filtration and veno-venous bypass and her condition significantly improved clinically afterward. We discuss the importance of suction filtration and veno-venous bypass in managing tricuspid valve endocarditis as an alternative in patients who are not ideal candidates for surgery and the need for more evidence regarding its effectiveness compared to surgery.

A Retrospective Review of the Natural Progression of Cardiac Vegetation.

Introduction: Infective endocarditis (IE) is a life-threatening condition with an annual mortality of up to 40%. Vegetations are the hallmark of IE, however, factors that affect the initial size and changes in size remain unclear. Our study aims to investigate the natural history of cardiac vegetation, including changes in size and/or resolution with adequate treatment, and to analyze factors that influence size and potential for persistence.Material and methods: We conducted a retrospective review of 102 patients admitted with native-valve endocarditis at Henry Ford Health System from September 1, 2017, to June 30, 2019. We included patients treated with six weeks of intravenous antibiotics who had both a diagnostic and a follow-up echocardiogram after antibiotic completion.The primary outcome was the change in vegetation size. Secondary measures included pathogen identification, valve involvement, number of complications, associated IV drug use, and co-infection with hepatitis B/C.Results: Of the 102 patients reviewed, 30 patients matched the inclusion criteria. There was a significant decrease in vegetation size after adequate antibiotic treatment. However, complete resolution was not often seen. A statistically significant relationship was seen between vegetation size, IV drug use, and Staphylococcal species (including both methicillin-susceptible Staphylococcus aureus [MSSA] and methicillin-resistant S. aureus [MRSA]), whereas a history of hepatitis B or C was not significantly related to vegetation size.Conclusion: Large vegetation may predict a higher risk of embolic complications and can be reduced with IV antibiotics, although complete resolution is not likely. IV drug use and Staphylococcal endocarditis influence vegetation size and embolic complications. We argue that these subgroups should be prioritized for early surgical intervention.

Infective Endocarditis in Children with Isolated VSD: A Single Center Study

Aim: To determine the characteristics of isolated ventricular septal defect (VSD) in association with infective endocarditis (IE) among children with isolated VSD and its outcome. Method: This was cross-sectional study. Data was collected prospectively from infective endocarditis patients with isolated ventricular septal defect (VSD), admitted in pediatric cardiology ward of The Children’s hospital and Institute of Child Health, Lahore. Study period was from September 2018 till March 2021. The data was analyzed by using SPSS-26. Result: Sixty patients of ventricular septal defect (VSD) with infective endocarditis (IE), fulfilling the inclusion criteria, were included in the current study. Mostly about 60% were male. Transthoracic Echocardiography was done for all the patients. Single vegetation was found among 68.3%, rest were having multiple vegetations. seen. Approximately 57% were having small size vegetations while remaining 43% were with moderated – large vegetations. Complications were reported in only 18% of the study population. Regarding outcome majority of the patients (90%) were successfully treated with medical management alone, while only 8.3% required surgical intervention as well. Only 1 out of 60 patients included in the study was expired. Characteristic of VSD, size of vegetation, and number of vegetations have significant influence on development of complications (p = &lt;0.05). Conclusion: Risk of complications among infective endocarditis with isolated VSD is comparatively greater with large vegetation and multiple number of vegetations as compared to single or small vegetation. Medical management is main stay of treatment while surgical intervention is usually required among infective endocarditis patients with DCSA-VSD &amp; subaortic-VSD. Key words: Ventricular septal defect (VSD), DCSA (doubly committed sub-arterial) VSD, Infective endocarditis (IE).

Clinical profile, microbiological spectrum, echocardiographic features, and in-hospital outcomes of patients with definite infective endocarditis

Background and Objectives: Infective endocarditis (IE) remains a serious clinical problem with a persistently high morbidity and mortality, despite the availability of improved diagnostic and treatment modalities in the developing world. We examined the microbiological spectrum, clinical profile, echocardiographic features, and in-hospital outcomes of patients with definitive IE. Materials and Methods: A total of 20 consecutive cases of definitive IE, admitted between March 2017 and August 2018, at a tertiary care cardiac center (Thiruvananthapuram Medical College, India) were included in the study and followed for 6 months. We compared the clinical profile, other features and outcomes of currently enrolled patients (Group-1) with 10 years back (2007) cohort (Group-2) of IE patients (n = 25) at the same institution. Results: The mean age of the Group-1 was 44.7 (±11.6) years, whereas those in Group-2 were 48.6 ± 12.9. The overall male to female sex ratio was 2.2: 1. The rheumatic heart disease (RHD) was the most common predisposing factor accounting for nearly 40% of all cases in both groups, congenital cardiac lesions accounting for 20% in both groups. The most common significant valve lesion was mitral regurgitation (45% vs. 40%P= 0.032). Fever was the most common complaint at the time of hospital admission in both groups (80% vs. 96%). The most common complication was congestive heart failure in both groups (60% vs. 56%). Blood cultures were positive only in 35% patients from Group-1 to 48% from Group-2 (P &lt; 0.01). The mean vegetation size in Group-1 was 7.6 mm and in Group-2 was 10.8 mm (P = 0.04). Patients with large-sized vegetation had increased incidence of heart failure, and embolic phenomena and mortality. Among Group-1, 5 (25%) patients have undergone surgery compared to Group-2, where only 4 (16%) patients have undergone surgery. The overall in hospital mortality in Group-1 was 5 (25%). Out of them, two patients expired after surgery (surgical mortality 40%). In Group-2, mortality was 7 (28%). Out of them, three patients expired after surgery (surgical mortality 42.8%). The majority (53.3%) of patients were in New York Heart Association Class II at the time of discharge. Conclusions: The average age of patients presenting with IE in India has increased, while the male predominance is maintained. RHD continues to be the most common predisposing factor. The lower culture positivity rate and lower rates of surgery are worrisome in Indian patients. Despite significant advances in medical technology over the last decade, mortality rate remains the same.

Reassessment of Vegetation Size as a Sole Indication for Surgery in Left-Sided Infective Endocarditis

Guidelines recommend surgery for left-sided infective endocarditis (LSIE) that is associated with large vegetations. Given that most patients who undergo surgery also have other indications (heart failure and/or uncontrolled infection), it is not settled whether surgery should be routinely recommended in patients with large vegetations but no other predictors of poor outcome. A total of 726 patients with definitive LSIE were included in our analysis. The mean age was 64.9years, and 61% were male. Multivariate analysis of all patients was performed to determine whether vegetation size is related to death in LSIE. Then patients were divided into two groups according to vegetation size: group A (>10mm, n=420) and group B (≤10mm, n=306). Univariate and multivariate analyses of group A patients were carried out to identify the variables related to death in this group. The impact of surgery on mortality in group A patients without heart failure or uncontrolled local infection (n=139) was assessed. Age, Staphylococcus aureus, perivalvular complications, heart failure, kidney failure, and septic shock, but not vegetation size, were associated with death. Patients with large vegetations showed increased mortality (31.7% in group A vs 24.8% in group B; P=.045). Group A had more valve rupture and valve regurgitation than group B, but heart failure (55% vs 53%; P=.678), stroke (22% vs 17.0%, P=.091), systemic embolism (39% vs 32%; P=.074), perivalvular complication (28% vs 28%; P=.865), and septic shock (15% vs 13%; P=.288) were similar in both groups. In patients from group A without heart failure or uncontrolled infection, mortality was similar with and without surgery (n=139; n=70 with surgery and n=69 without surgery; mortality, 18.6% vs 11.6%, respectively; P=.251). Large vegetations identify patients with poor outcomes in the context of LSIE. However, surgery is not associated with a better prognosis in patients with large vegetations if they do not present with another predictor of poor outcome such as heart failure or uncontrolled infection. These findings challenge whether vegetation size alone should be an indication for surgery in LSIE.

Vegetation Size, Multiplicity, and Position in Patients With Infective Endocarditis

BackgroundInfective endocarditis is a life-threatening condition and is associated with embolic events. We aimed to evaluate the association of vegetation size, multiplicity, and position with cerebral embolism and late mortality in patients with infective endocarditis. MethodsWe retrospectively reviewed patients with infective endocarditis who were admitted to a single institution between November 2005 and August 2017. A total of 419 patients with infective endocarditis were included in the study, 273 of whom had undergone surgery. The primary endpoint was all-cause mortality, and the secondary endpoint was cerebral embolism. Multivariate Cox regression and logistic regression analyses were performed to identify independent risk factors for 30-day mortality, late mortality, and cerebral embolism. ResultsAge (hazard ratio [HR] 1.02; 95% confidence interval [CI], 1.00 to 1.04), renal failure (HR 4.21; 95% CI, 2.67 to 6.65), surgery (HR 0.31; 95% CI, 0.21 to 0.46), and Acute Physiology and Chronic Health Evaluation II score (HR 1.08; 95% CI, 1.01 to 1.15) were associated with late mortality. Vegetation size, multiplicity, and position were not significantly associated with late mortality, but a mitral vegetation size of greater than 10 mm (odds ratio 2.25; 95% CI, 1.32 to 3.84) was an independent risk factor for cerebral embolism. ConclusionsA vegetation size of greater than 10 mm and the mitral position were found to be significant risk factors for cerebral embolism, and for this group, early surgery might be considered to prevent cerebral embolism.