Aortic valve surgery in children with infective endocarditis

There is limited data on the outcomes of children who undergo surgery for aortic valve infective endocarditis (IE), and the optimal surgical approach remains controversial. We investigated the long-term outcomes of surgery for aortic valve IE in children, with a particular focus on the Ross procedure. A retrospective review of all children who underwent surgery for aortic valve IE was performed at a single institution. Between 1989 and 2020, 41 children underwent surgery for aortic valve IE, of whom 16 (39.0%) underwent valve repair, 13 (31.7%) underwent the Ross procedure, 9 (21.9%) underwent a homograft root replacement, and 3 (7.3%) underwent a mechanical valve replacement. Median age was 10.1 years (interquartile range [IQR], 5.4-14.1). The majority of children (82.9%, 34/41) had underlying congenital heart disease, while 39.0% (16/41) had previous heart surgery. Operative mortality was 0.0% (0/16) for repair, 15.4% (2/13) for the Ross procedure, 33.3% (3/9) for homograft root replacement, and 33.3% (1/3) for mechanical replacement. Survival at 10 years was 87.5% for repair, 74.1% for Ross, and 66.7% for homograft (p>0.05). Freedom from reoperation at 10 years was 30.8% for repair, 63.0% for Ross, and 26.3% for homograft (p=0.15 for Ross vs. repair, p=0.002 for Ross vs. homograft). Children undergoing surgery for aortic valve IE have acceptable long-term survival, although the need for long-term reintervention is significant. The Ross procedure appears to be the optimal choice when repair is not feasible.

Molecular epidemiology of Bartonella quintana endocarditis in patients from Israel and Eastern Africa

BACKGROUND

Bartonella quintana is an important cause of culture-negative endocarditis. Although humans have been considered as its only reservoir, recent studies showed that macaque species are also reservoirs of B. quintana. Based on multi-locus sequence typing (MLST) B. quintana strains have been classified into 22 sequence types (STs), with 7 STs exclusively found in humans. Data regarding the molecular epidemiology of B. quintana endocarditis is limited to only 3 STs identified in 4 patients from Europe and Australia. We studied B. quintana endocarditis acquired in Eastern Africa or Israel to investigate the genetic diversity and clinical relatedness of B. quintana from distinct geographic regions.

METHODS

Eleven patients with B. quintana endocarditis, 6 from Eastern Africa and 5 from Israel, were studied. DNA was extracted from cardiac tissue or blood specimens and analyzed by MLST based on 9 genetic loci. An evolutionary relationship between STs was visualized by a minimum spanning tree. A phylogenetic tree was constructed with the concatenated sequences (4271 bp) of the 9 loci using the maximum-likelihood method.

RESULTS

Six strains were classified into previously described STs while 5 strains were identified for the first time and classified into new STs 23-27 which clustered with the previously reported STs 1-7 from human strains found in Australia, France, Germany, the USA, Russia, and the former Yugoslavia, without indication of geographical structuring. ST2 was the most prevalent ST, found in 5 of 15 patients with endocarditis (33.3%). ST26 appears to be a primary founder of the human lineage.

CONCLUSIONS

The new and previously reported human STs form a single human lineage, clearly separated from the other 3 B. quintana lineages of cynomolgus, rhesus, and Japanese macaques. From evolutionary perspectives, these findings support the assumption that B. quintana has co-evolved with host species to form a host-speciation pattern. ST26 is suggested herein as a primary founder of the human lineage and may be key to explore where B. quintana had first originated; ST2 is a dominant genetic type associated with B. quintana endocarditis. To confirm these findings, additional worldwide molecular epidemiological studies are required.

Stroke and endocarditis: Reversing the point of view. A retrospective, cohort study

STUDY OBJECTIVES

The primary objective of our study is to assess the endocarditis prevalence in patients admitted to the emergency department (ED) for a primary diagnosis of acute stroke (AS). Secondary objectives are the identification of early markers of endocarditis in AS patients and the analysis of the short-term outcome of this population.

METHODS

In this observational, retrospective, cohort study we enrolled consecutive adult patients with a primary diagnosis of AS admitted to the Stroke Unit or to the Neurological Intensive Care Unit of our hospital who were then discharged with a diagnosis of endocarditis. These patients were then compared with age and sex-matched controls with a diagnosis of AS and atrial fibrillation.

RESULTS

Endocarditis prevalence in patients admitted to the Stroke Unit or Neurological Intensive Care Unit with a primary diagnosis of AS is 1.0% (95% confidence interval 0.61-1.55). Fever on ED admission, concomitant cancer, low hemoglobin, low lymphocyte levels, a high neutrophils count and erythrocyte sedimentation levels could early differentiate among AS patients, those with endocarditis from those with atrial fibrillation. A moderate-to-severe valvular regurgitation is strongly suggestive of endocarditis. The short term-outcome is markedly worse in endocarditis patients compared to patients with atrial fibrillation, in terms of in-hospital mortality and discharge disability.

CONCLUSIONS

Endocarditis prevalence in patients admitted for a primary diagnosis of AS is low, but this etiology leads to a poor outcome. Some laboratory, clinical-epidemiological and echocardiographic parameters may help the physician to early recognize this condition and, consequently, to promptly start an antibiotic therapy.

Risk factors for Gram-negative bacterial infection of cardiovascular implantable electronic devices: multicentre observational study (CarDINe Study)

BACKGROUND

Infections of cardiovascular implantable electronic devices (CIED) are mainly due to Gram-positive bacteria (GPB). Data about Gram-negative bacteria CIED (GNB-CIED) infections are limited. This study aimed to investigate risk factors, clinical and diagnostic characteristics, and outcome of patients with GNB-CIED.

METHODS

A multicentre, international, retrospective, case-control-control study was performed on patients undergoing CIED implantation from 2015 to 2019 in 17 centres across Europe. For each patient diagnosed with GNB-CIED, one matching control with GPB-CIED infection and two matching controls without infection were selected.

RESULTS

A total of 236 patients were enrolled: 59 with GNB-CIED infection, 59 with GPB-CIED infection and 118 without infection. No between-group differences were found regarding clinical presentation, diagnostic and therapeutic management. A trend toward a higher rate of fluorodeoxyglucose positron emission computed tomography (FDG PET/CT) positivity was observed among patients with GNB than in those with GPB-CIED infection (85.7% vs. 66.7%; P = 0.208). Risk factors for GNB-CIED infection were Charlson Comorbidity Index Score (relative risk reduction, RRR = 1.211; P = 0.011), obesity (RRR = 5.122; P = 0.008), ventricular-pacing ventricular-sensing inhibited-response pacemaker implantation (RRR = 3.027; P = 0.006) and right subclavian vein site of implantation (RRR = 5.014; P = 0.004). At 180-day survival analysis, GNB-CIED infection was associated with increased mortality risk (HR = 1.842; P = 0.067).

CONCLUSIONS

Obesity, high number of comorbidities and right subclavian vein implantation site were associated with increased risk of GNB-CIED infection. A prompt therapeutic intervention that may be guided using FDG PET/CT is suggested in patients with GNB-CIED infection, considering the poorer outcome observed in this group.

[Massive pancarditis-autopsy report]

We report on a 69-year-old man suffering from chronic progressive oligoarthritis (localized in metacarpal and knee joints), which clinically was interpreted as steroid-sensitive seronegative chronic arthritis. The patient died from sudden death at the emergency department after a 4-week history of increasing cough and dyspnea (meanwhile obtaining negative testing results for SARS-CoV-2). During the autopsy, we found massive pancarditis affecting all cardiac compartments, in particular exhibiting constrictive pericarditis, myocarditis, and multivalvular endocarditis. Microscopically, interstitial myocarditis could be observed. Performing extensive molecular analyses, we detected Tropheryma whipplei in the tissue specimens of the heart, but not in various duodenal tissue probes or in the synovial membrane. Taken together, in the present case the cause of death was acute cardiac failure due to multivalvular pancarditis due to T. whipplei. Besides from classical symptoms and morphological signs, Whipple's disease may present with various features. Regarding the differential diagnosis of a chronic multisystem disorder with aspects of hitherto unknown arthralgia, Whipple's disease should be considered.

Periprosthetic joint infection caused by kytococcus schroeteri: The first reported case and a review of the literature

Oftentimes, Gram-positive cocci are the cause for periprosthetic joint infections (PJI). Most of these infections include bacteria such as Staphylococcus aureus, Staphylococcus epidermidis or other coagulase-negative staphylococci. We here present the first case of a PJI caused by Kytococcus schroeteri. While being a Gram-positive coccus, it is very rarely the cause for infections in the human body. K. schroeteri is part of the micrococcus branch and often encountered as a symbiotic bacterium living on the skin. Regarding its pathogenic potential, not a lot is known since less than a few dozen human infections have been reported worldwide. Furthermore, many of the cases reported are either associated with implanted material, especially heart valves, or associated with patients whose immune response is deficient. Only 3 reports of osteoarticular infections are described so far.

AngioVac debulking of a tricuspid valve mass following complex lead extraction in a rare case of Austrian syndrome: a case report

Background

The European Society of Cardiology recommends surgical valvular intervention in right-sided infective endocarditis for persistent vegetations >20 mm after recurrent pulmonary emboli, infection with a difficult-to-eradicate organism with >7 days of persistent bacteraemia, or tricuspid regurgitation causing right-sided heart failure. In this case report, we discuss the role of percutaneous aspiration thrombectomy for a large tricuspid valve (TV) mass as an alternative to surgery due to poor surgical candidacy in a patient with Austrian syndrome, following a complex implantable cardioverter defibrillator (ICD) device extraction.

Case summary

A 70-year-old female presented to the emergency department after being found acutely delirious at home by family. Infectious workup was notable for growth of Streptococcus pneumoniae in the blood, cerebrospinal, and pleural fluid. Transoesophageal echocardiogram was pursued in the setting of bacteraemia and revealed a mobile mass on the TV consistent with endocarditis. Given the size and embolic potential of the mass and eventual need for ICD replacement, the decision was made to pursue extraction of the valvular mass. The patient was a poor candidate for invasive surgery, so we opted to perform percutaneous aspiration thrombectomy. After the ICD device was extracted, the TV mass was successfully debulked using the AngioVac system without complication.

Discussion

Percutaneous aspiration thrombectomy of right-sided valvular lesions has been introduced as a minimally invasive approach to avoid or delay valvular surgery. When intervention is indicated for TV endocarditis, AngioVac percutaneous thrombectomy may be a reasonable operative approach, particularly in patients who are at high risk for invasive surgery. We report a case of successful AngioVac debulking of a TV thrombus in a patient with Austrian syndrome.

Bilateral pulmonary septic embolectomy in the setting of multivalvular acute infective endocarditis surgery

We report a case of multivalvular acute infective endocarditis associated with a bilateral septic pulmonary embolism. The patient underwent aortic and tricuspid valve replacement, mitral valve anterior leaflet debridement and bilateral pulmonary septic embolectomy, followed by a 6-week intravenous antibiotic treatment. We present our multidisciplinary approach for the management of such complex cases.

Lactococcus endocarditis after Bentall procedure presenting with intracranial hemorrhage

Background

Endocarditis is more common in patients with cardiac prostheses. A Bentall procedure entails surgical replacement of the aortic valve, aortic root, and ascending aorta with re-implantation of coronary arteries into the graft.

Case

65-year-old male with history of atrial fibrillation on rivaroxaban, bicuspid aortic valve, and ascending aortic aneurysm with a history of a Bentall procedure two years prior, presented with headache and dysarthria for one day. National Institutes of Health Stroke Scale was 3 and CT head showed 2.7 cm left frontal hematoma with extension into the subarachnoid space. Andexanet alfa was given for rivaroxaban reversal followed by cerebral angiogram which showed 5 mm intracranial inferior MCA aneurysm and embolization and coil placement was done. Blood cultures grew Lactococcus garvieae and transesophageal echocardiogram revealed aortic valve thickening and vegetation on the non-coronary cusp. He was subsequently treated with six weeks of IV ceftriaxone and Gentamycin.

Conclusion

With increasing use of bioprosthetic valves, the possibility of infective endocarditis with uncommon pathogens should be kept in mind. Lactococcus commonly affects native valves, however it can affect bioprosthetic valves and can present with mycotic aneurysms.

Nafcillin Augmentation of Daptomycin and Cathelicidin LL-37 Killing of Methicillin-resistant Staphylococcus epidermidis: Foundations of Successful Therapy of Endocarditis

A patient with methicillin-resistant Staphylococcus epidermidis (MRSE) tricuspid valve endocarditis had refractory bacteremia while on vancomycin and daptomycin monotherapies that was cleared in 24 h upon addition of nafcillin to daptomycin. In vitro studies on the isolate demonstrated enhancement of daptomycin killing by nafcillin in both planktonic cells and biofilm. Nafcillin exposure also sensitized MRSE to killing by human neutrophils and cathelicidin antimicrobial peptide LL-37. Fluorescent microscopy showed increased daptomycin and LL-37 binding to the MRSE bacterial surface upon nafcillin treatment. Ceftaroline also increased MRSE killing by daptomycin in planktonic cultures and biofilms, as well as daptomycin and LL-37 binding on the bacterial surface. By harnessing augmentation of cationic peptide, innate immune system, and daptomycin killing of MRSE, nafcillin, ceftaroline, and possibly also other β-lactams, may serve an important role in the therapy of S. epidermidis endocarditis. Clinical studies will be needed to determine how early these regimens should be deployed to optimize clinical outcome.

Infective endocarditis of quadricuspid aortic valve

BACKGROUND

Infective endocarditis of the aortic valve is a relatively common disease presentation, with surgical intervention a mainstay of treatment in severe cases. Quadricuspid aortic valves are a rare spontaneous developmental anomaly that are more likely to be asymptomatic, and less likely to require a full valve replacement than their hypocuspid counterparts. However, there is very little literature addressing infective endocarditis of this valve variant.

CASE PRESENTATION

This case report presents a case of infective endocarditis of a quadricuspid aortic valve that required replacement with a surgical bioprosthetic valve. The patient is a 30 year old male with a history of polysubstance use, upper extremity aneurysm, and prior tricuspid valve endocarditis. Surgical aortic valve replacement was performed with a 25 mm tissue valve via median sternotomy.

CONCLUSIONS

The patient made a full recovery after surgical aortic valve replacement and a course of antibiotics and was discharged home without any complications. This supports that surgical aortic valve replacement is feasible and safe in patients with polycuspid aortic valve endocarditis.

Ten years' experience with the sutureless aortic valve replacement: incidence and predictors for survival and valve durability at follow-up

OBJECTIVES

Aortic valve replacement with a sutureless prosthesis [sutureless aortic valve replacement (Su-AVR)] is an option for patients with severe aortic valve stenosis. However, data regarding long-term outcomes and prosthesis durability are still lacking.

METHODS

All consecutive patients who successfully underwent Su-AVR with the Perceval valve in our centre between 2010 and 2020 were included in the analysis and followed prospectively with echocardiography. Risk factor analysis was performed to assess variables associated with worse survival and bioprosthetic valve failure.

RESULTS

Study population consisted of 547 patients: the mean age was 76.4 (5.2) years, 51% were female and the mean logistic EuroSCORE was 13% (11). The median survival was 7.76 years [95% confidence interval (CI) = 6.9-8.6]. Risk factor analysis identified age [hazard ratio (HR) 1.06, 95% CI 1.03-1.11; P < 0.001), EuroSCORE II (HR 1.08, 1.02-1.13; P < 0.001), baseline dialysis (HR 2.14, 95% CI 1.4-4.4; P = 0.038) and postoperative acute kidney injury ≥2 (HR 8.97, 95% CI 4.58-17.6; P < 0.001) as factors significantly correlated with worse survival. The reported HRs for age are per 1 year and for EuroSCORE II is 1 percentage point. Structural valve deterioration (SVD) was observed in 23 patients, of whom 19 underwent reintervention (median freedom from SVD 10.3 years). In multivariable Cox analysis, age (HR 0.89, 95% CI 0.82-0.95; P < 0.001) was found to be a significant predictor of SVD. Overall, 1.8% was referred for prosthetic valve endocarditis (confirmed or suspected) during follow-up. One patient showed moderate non-SVD and none developed prosthetic valve thrombosis.

CONCLUSIONS

The sutureless valve represents a reliable bioprosthesis for aortic valve replacement in patients with a 10-year life expectancy. Younger age at the time of implant is the only factor associated with the risk of long-term SVD.

Transvenous lead extraction in patients with systemic cardiac device-related infection-Procedural outcome and risk prediction: A GALLERY subgroup analysis

BACKGROUND

Transvenous lead extraction (TLE) has evolved as one of the most crucial treatment options for patients with cardiac device-related systemic infection (CDRSI).

OBJECTIVE

The aim of this study was to characterize the procedural outcome and risk factors of patients with CDRSI undergoing TLE.

METHODS

A subgroup analysis of patients with CDRSI of the GALLERY (GermAn Laser Lead Extraction RegistrY) database was performed. Predictors for complications, procedural failure, and all-cause mortality were evaluated.

RESULTS

A total of 722 patients (28.6%) in the GALLERY had "systemic infection" as extraction indication. Patients with CDRSI were older (70.1 ± 12.2 years vs 67.3 ± 14.3 years; P < .001) and had more comorbidities than patients with local infections or noninfectious extraction indications. There were no differences in complete procedural success (90.6% vs 91.7%; P = .328) or major complications (2.5% vs 1.9%; P = .416) but increased procedure-related (1.4% vs 0.3%; P = .003) and all-cause in-hospital mortality (11.1% vs 0.6%; P < .001) for patients with CDRSI. Multivariate analyses revealed lead age ≥10 years as a predictor for procedural complications (odds ratio [OR] 3.23; 95% confidence interval [CI] 1.58-6.60; P = .001). Lead age ≥10 years (OR 2.57; 95% CI 1.03-6.46; P = .04) was also a predictor for procedural failure. We identified left ventricular ejection fraction <30% (OR 1.70; 95% CI 1.00-2.99; P = .049), age ≥75 years (OR 2.1; 95% CI 1.27-3.48; P = .004), chronic kidney disease (OR 1.92; 95% CI 1.17-3.14; P = .01), and overall procedural complications (OR 5.15; 95% CI 2.44-10.84; P < .001) as predictors for all-cause mortality.

CONCLUSION

Patients with CDRSI undergoing TLE demonstrate an increased rate of all-cause in-hospital, as well as procedure-related mortality, despite having comparable procedural success rates. Given these data, it seems paramount to develop preventive strategies to detect and treat CDRSI in its earliest stages.

Pseudoaneurysm of the left ventricular free wall occurring after cardiac surgery of endocarditis affecting mitral and aortic valves: a case report

BACKGROUND

Infective endocarditis remains a serious condition. Left ventricular pseudoaneurysm may complicate the clinical course of infective endocarditis or occur postoperatively.

CASE PRESENTATION

We describe a case of a pseudoaneurysm of the left ventricular lateral wall which developed one month following cardiac surgery of active endocarditis affecting aortic and mitral valves. The diagnosis was established by transthoracic echocardiography and computed tomography angiography of the chest. Urgent cardiac surgery is performed with excision of the pseudoaneurysm and direct closure of the defect. The patient had a complete recovery and was discharged on the twelfth postoperative day.

CONCLUSIONS

Left ventricular pseudoaneurysms are rare but potentially fatal. The symptoms revealing such complications are very diverse. Surgical treatment can be offered to younger patients.

Prognostic role of endocarditis in isolated tricuspid valve surgery. A propensity-weighted study

OBJECTIVES

The role of the underlying etiology in isolated tricuspid valve surgery has not been investigated extensively in current literature. Aim of this study was to analyse outcomes of patients undergoing surgery due to endocarditis compared to other pathologies.

METHODS

The SURTRI study is a multicenter study enrolling adult patients who underwent isolated tricuspid valve surgery (n = 406, 55 ± 16 y.o.; 56% female) at 13 international sites. Propensity weighted analysis was performed to compare groups (IE group n = 107 vs Not-IE group n = 299).

RESULTS

No difference was found regarding the 30-day mortality (Group IE: 2.8% vs Group Not-IE = 6.8%; OR = 0.45) and major adverse events. Weighted cumulative incidence of cardiac death was significantly higher for patients with endocarditis (p = 0.01). The composite endpoint of cardiac death and reoperation at 6 years was reduced in the Group IE (63.2 ± 6.8% vs 78.9 ± 3.1%; p = 0.022). Repair strategy resulted in an increased late survival even in IE cases.

CONCLUSIONS

Data from SURTRI study report acceptable 30-day results but significantly reduced late survival in the setting of endocarditis of the tricuspid valve. Multi-disciplinary approach, repair strategy and earlier treatment may improve outcomes.

Infective endocarditis in adult patients with congenital heart disease

BACKGROUND

Congenital Heart Disease (CHD) predisposes to Infective Endocarditis (IE), but data about characterization and prognosis of IE in CHD patients is scarce.

METHODS

The ESC-EORP-EURO-ENDO study is a prospective international study in IE patients (n = 3111). In this pre-specified analysis, adult CHD patients (n = 365, 11.7%) are described and compared with patients without CHD (n = 2746) in terms of baseline characteristics and mortality.

RESULTS

CHD patients (73% men, age 44.8 ± 16.6 years) were younger and had fewer comorbidities. Of the CHD patients, 14% had a dental procedure before hospitalization versus 7% in non-CHD patients (p < 0.001) and more often had positive blood cultures for Streptococcus viridans (16.4% vs 8.8%, p < 0.001). As in non-CHD patients, IE most often affected the left-sided valves. For CHD patients, in-hospital mortality was 9.0% vs 18.1% in non-CHD patients (p < 0.001), and also, during the entire follow-up of 700 days, survival was more favorable (log-rank p < 0.0001), even after adjustment for age, gender and major comorbidities (Hazard Ratio (HR) 0.68; 95%CI 0.50-0.92). Within the CHD population, multivariable Cox regression revealed the following effects (HR and [95% CI]) on mortality: fistula (HR 6.97 [3.36-14.47]), cerebral embolus (HR 4.64 [2.08-10.35]), renal insufficiency (HR 3.44 [1.48-8.02]), Staphylococcus aureus as causative agent (HR 2.06 [1.11-3.81]) and failure to undertake surgery when indicated (HR 5.93 [3.15-11.18]).

CONCLUSIONS

CHD patients with IE have a better outcome in terms of all-cause mortality. The observed high incidence of dental procedures prior to IE warrants further studies about the current use, need and efficacy of antibiotic prophylaxis in CHD patients.

Fusobacterium nucleatum endocarditis: a case report and literature review

Fusobacteria is anaerobic gram-negative rods, which frequently colonize the oral cavity and can rarely cause deadly diseases in humans. The two most commonly found in this group of bacteria are fusobacterium necrophorum and fusobacterium nucleatum. Only a handful of cases of endocarditis due to fusobacterium have been reported. We describe an 86-year-old male who had a recent tooth extraction presenting to the emergency department with weakness lightheadedness, and pain in his right elbow. He had a low-grade fever of 100.8°. The patient was discharged home but came back less than 24 hours with a fever of 102° and chills and again after the second discharge with sepsis of unknown origin. A week after initial blood cultures were drawn, fusobacterium nucleatum grew in one of two sets and his transesophageal echocardiogram revealed vegetation on his mitral valve. The patient was then successfully treated with a six weeks course of ampicillin-sulbactam. This case is followed by a review of the literature.

A triple tunnel from the mid-calf to the femoral vein in patient with severe dementia

Achieving the ideal exit site is the new philosophy for complicated vascular access patients. Recent publications have described multiple venous access solutions such as tunneling to the scapular region, the chest to the arm, and from the femoral vein to the abdominal and patellar region. In the patients afflicted with delirium, dementia, or confusion even these sites may not be sufficient. The following case study illustrates a triple tunneled femoral catheter on a non-cooperative patient with inoperable endocarditis to be discharged and treated with long term antibiotics.

Sinus of Valsalva Pseudoaneurysm Complicating Infective Endocarditis Causing Right Ventricular Inflow Obstruction

Sinus of Valsalva pseudoaneurysm (SVpA) is a rare cause of right ventricular inflow obstruction. We report such a case presented with atrial flutter and cardiogenic shock caused by tricuspid valve obstruction by a narrow-necked right SVpA complicating aortic valve infective endocarditis demonstrated on transesophageal echocardiography and cardiac computed tomography. Despite restoration of sinus rhythm, the patient ran a fatal course due to aneurysmal rupture. We show the value of transesophageal echocardiography in evaluating unstable patients with cardiogenic shock, and the need of urgent surgery in selected patients to avoid a dismal outcome.

Infectious endocarditis without intracardiac devices or underlying structural heart disease

OBJECTIVE

To describe clinical, microbiological and echocardiographic aspects of endocarditis in a specific group of patients without intracardiac devices or underlying structural heart disease.

METHOD

Retrospective study, clinical records and echocardiographic reports were reviewed during the period 1997 to 2020. Duke's modified criteria were applied. Statistical analysis: univariate expressed in frequencies, using measures of dispersion and central tendency.

RESULTS

30,000 echocardiographic reports were reviewed, only 1350 had infectious endocarditis as a reason for sending, of which 248 cases were selected. The mean age was 48.1 ± 16.7 years. 140 men (56%) and 108 women (44%). The most frequent echocardiographic sign was vegetation, in 278 (93.60%), and most common location was mitral (35.55%), with a higher number of cases in the right ventricle than expected. The most common systemic disease was kidney disease, in 135 (41.08%). A case of Streptococcus thoraltensis not previously reported in Mexico was identified.

CONCLUSIONS

The presence of infectious endocarditis has increased due to invasive in-hospital and drug procedures. Due to their complexity, multidisciplinary teams are indispensable.

Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study

BACKGROUND

Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention.

METHODS

Participants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs.

RESULTS

Implementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team's advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing.

CONCLUSION

Integration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.

A Rodential Reckoning: A Case Report and Systematic Review of Streptobacillary Endocarditis

Introduction

Endocarditis is a rare, often fatal complication of rat bite fever caused by Streptobacillus moniliformis. Only 39 cases have been reported (including this case) as of 2022. We describe a case and aim to perform this entit's first systematic literature review.

Methods

We performed a systematic review in CENTRAL, EMBASE, MEDLINE, SciELO, and LILACS. The terms used were terms used were (but not limited to) rat bite fever, Streptobacillus moniliformis, Spirillum minus, and endocarditis. We included all abstracts and articles with patients with echocardiographic or histologic-proven endocarditis. In case of discordance, a third reviewer was involved. Our protocol was submitted to PROSPERO (CRD42022334092). We also performed searches for studies on the reference list of included articles.

Results

We retrieved 108 and included 36 abstracts and articles. A total of 39 patients (including our report) were identified. The mean age was 41.27, and 61.5% were males. The most common findings were fever, murmur, arthralgias, fatigue, splenomegaly, and rash. Underlying heart disease was present in 33%. Exposure to rats was noted in 71.8% of patients, with 56.4% recalling a rat bite. Anemia was seen in 57%, leukocytosis in 52%, and elevated inflammatory markers in 58% that had lab work performed. The mitral valve was most affected, followed by the aortic, tricuspid, and pulmonary valves. Surgical intervention was required in 14 (36%) cases. Of those, 10 required valve replacement. Death was reported in 36% of cases. Unfortunately, the literature available is limited to case series and reports.

Conclusion

Our review allows clinicians to suspect better, diagnose, and manage Streptobacillary endocarditis.

Characteristics and outcomes of angiovac-assisted debulking of intracardiac masses, thrombi, and endocarditis

BACKGROUND

Traditional management for right-sided infective endocarditis and other adherent masses centers around balancing the risks and benefits of open surgical removal against medical therapy.

METHODS

Single-center study analysis of 19 patients who underwent vacuum-assisted debulking and/or en bloc removal of right-sided infective endocarditis and other adherent masses between September 2017 and November 2021. Clinical outcomes during the perioperative period, postoperative period, hospital course, and post-discharge were analyzed.

RESULTS

We included 12 male and 7 female patients with an average age 47.4 ± 16.8. Relevant risk factors included 47.4% of patients with active intravenous drug use (IVDU), 21.1% of patients with a history of permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD), and 5.3% of prior malignancy with mediastinal radiation. 31.6% of patients had documented right-sided masses from a non-infectious etiology, while 68.4% of patients were noted to have right-sided infective endocarditis (RSIE). All patients were found to have large, mobile masses or vegetations at high risk for embolization to the pulmonary vasculature. Average in-hospital length of stay was 17.8 ± 12.2 days, blood cultures cleared postoperatively in 8.9 ± 7.3 days, periprocedural mortality was 0%, subsequent open surgical valvular repair during the same admission was 5.3%, and in-hospital mortality was 5.3%. Within 6 weeks of follow-up, 15.8% of patients were readmitted for recurrence of bacteremia, 10.5% of patients were found to have new pulmonary embolism, and 15.8% of patients underwent open surgical valvular repair. Total death after 1-year and 2-years was 15.8% and 5.3%, respectively. Recurrence of bacteremia was 21.1% within 1-year.

CONCLUSION

AngioVac is a viable therapeutic strategy for select patients with intravascular and intracardiac right-sided masses including thrombi, emboli, or infective masses such as endocarditis.