Infective Endocarditis: Update on Epidemiology, Outcomes, and Management

[Gustav Mahler: tragic life, mysterious illness, early death : Could intensive care medicine have saved him today?]

BACKGROUND

Gustav Mahler was a composer of the late Romantic period, one of the most famous conductors of his time and, as opera director, one of the most important reformers of musical theatre. Mahler's life, illnesses, death and dying are little or not at all known to many.

OBJECTIVES

Which illnesses determined Mahler's life? Could his early death have been avoided? From today's point of view, could modern intensive care medicine have helped him?

MATERIAL AND METHODS

A detailed analysis of Mahler's diseases was performed using scientific databases (medline, pubmed). All published articles were examined in detail.

RESULTS

Gustav Mahler was born in 1860 in Kalischt (Bohemia) and learned to play the accordion and piano at an early age. He studied music at the Vienna Conservatory from 1875 and completed his composition studies in 1878. Kapellmeister positions followed in several cities, from 1887 at the Vienna Court Opera and from 1908 at the Metropolitan Opera in New York. Mahler suffered from many illnesses, especially tonsillitis and haemorrhoids. In 1907 he was diagnosed with a mitral valve defect, in 1911 he developed bacterial endocarditis caused by streptococci, as a result of which Mahler died in Vienna in 1911. His life was marked by personal and health tragedies.

DISCUSSION

Mahler was an outstanding personality who left behind an extensive oeuvre. Among the compositional highlights are his 10 symphonies and the song compositions. Recurrent streptococcal infections led to mitral valve disease and endocarditis, the consequences of which caused Mahler's untimely death. Today's modern cardiology and intensive care medicine could have prolonged his life, but unfortunately this was not possible at the time when he was diagnosed with endocarditis.

Molecular diagnosis of infective endocarditis from culture-negative valve samples in a tertiary hospital in Iran

The aim of this study was to investigate the prevalence of Tropheryma whipplei, Chlamydia psittaci, Chlamydia pneumoniae, Legionella, Brucella, and Francisella tularensis in valve samples from endocarditis patients using the real-time PCR method at a major referral heart hospital in Iran. In this study, 146 paraffin-embedded tissue samples from the heart valves of patients with clinical and pathological evidence of infective endocarditis (IE), who underwent heart valve replacement surgery between 2016 and 2020 at Tehran Heart Center were collected. After DNA extraction from paraffin-embedded valve tissue samples, they were surveyed for the presence of T. whipplei, C. psittaci, C. pneumoniae, Legionella, Brucella, and F. tularensis using quantitative real-time PCR (qPCR). The 16S rRNA gene sequence analysis was used for accurate species identification. Based on the molecular results, T. whipplei, Chlamydia spp., and Legionella spp. were detected in 10 (6.84%), 6 (4.1%), and 3 (2.05%) valve samples, respectively. In addition, one of six positive samples for Chlamydia spp. was identified as C. psittaci. No positive samples for F. tularensis and Brucella were found. In addition, all control valve samples were negative for all investigated pathogens. The findings suggest that specific bacterial species such as T. whipplei, Chlamydia spp., and Legionella spp. are associated with the development of IE. Considering the life-threatening nature of IE, it is critical for healthcare systems to prioritize the identification of its causative agents and develop targeted treatment strategies.IMPORTANCEInfective endocarditis (IE) is a serious and potentially life-threatening condition, and it is associated with significant morbidity, mortality, and complications, making it a major concern in both global and national healthcare systems. Late diagnosis and failure to receive appropriate treatment for patients with culture-negative endocarditis caused by hard-to-grow bacteria can lead to the death of patients. Unfortunately, in Iran, less attention is paid to the role of organisms that are difficult to cultivate in laboratory settings such as Tropheryma whipplei, Chlamydia psittaci, Chlamydia pneumoniae, Legionella, Brucella, and Francisella tularensis in causing culture-negative endocarditis, and these pathogens are overlooked by infectious, cardiologists, and health officials. This study underscores the need for special attention in the diagnosis of the agents of IE.

An Infective Endocarditis Case Report Involving Both Native Aortic and Mitral Valves Due to Streptococcus Vestibularis

Infective endocarditis (IE) is a life-threatening disease, with its mortality rate varying depending on the infectious agent. Streptococci are among the most common causes of infective endocarditis. However, Streptococcus vestibularis has rarely been associated with human infections, typically affecting patients with underlying conditions such as immunosuppressive diseases, valve replacement, rheumatic heart disease, and hemodialysis. We present the case of a 26-year-old man who presented with fever, unanticipated weight loss, and fatigue. Although no typical risk factors for infective endocarditis were identified at admission, transesophageal echocardiography revealed a bicuspid aortic valve with calcification, paravalvular aortic abscess formation, and vegetations on the anterior leaflet of the mitral valve. Blood cultures grew S. vestibularis, which was initially sensitive to benzylpenicillin but developed emergent resistance on the third day of the antibiotic treatment. Subsequently, ceftriaxone therapy was initiated, and blood cultures became sterile on day 10. The patient eventually underwent aortic valve replacement. We report the first known case of native aortic and mitral valve endocarditis caused by S. vestibularis, accompanied by a paravalvular abscess around the native aortic valve, in a patient who had no typical risk factors for infective endocarditis, except for a bicuspid aortic valve.

Oxidative Stress in Aortic Valves Associated with Infective Endocarditis: A Report on Three Cases

Background/Objectives: Infective endocarditis (IE) most commonly results from infections by Gram-positive bacteria, and, in this condition, the redox homeostasis is lost due to the overproduction of H2O2, leading to the overstimulation of the immune system and the upregulation of the production of proinflammatory cytokines. The aim of this study was to evaluate the levels of oxidative biomarkers and the enzymatic and non-enzymatic antioxidant systems in subjects with IE. Methods: The study included three cases with IE that had undergone aortic valve replacement (AVR) surgery that was complicated by IE, comparing them with subjects with AVR without IE. We determined the malondialdehyde (MDA), total antioxidant capacity (TAC), carbonyl group concentration, glutathione (GSH), thiols and the nitrate/nitrite ratio (NO3-/NO2-) in homogenized tissue from the cardiac valves. We also measured the activity of glutathione-S-transferase (GST), glutathione peroxidase (GPx), glutathione reductase (GR) and thioredoxin reductase (TrxR). The superoxide dismutase (SOD) isoforms and peroxidase activity were determined using native gels. Results: There were increases in the activity of antioxidant enzymes such as GST, SOD isoforms and peroxidases (p ≤ 0.01) and decreases in oxidative stress markers such as GSH (p = 0.05); meanwhile, MDA and carbonylation were increased (p ≤ 0.05). Conclusions: The results suggest that bacterial infections favor oxidative stress in the aortic valves, which increases the SOD isoforms and peroxidase activity. This contributes to the loss of the intricate redox homeostasis system in patients with IE, causing a positive feedback loop in the oxidative background that results in damage to the heart, likely leading to a fatal outcome.

Heartfelt Impact: A Descriptive Analysis of Ceftaroline-Containing Regimens in Endocarditis due to Methicillin-Resistant Staphylococcus aureus

INTRODUCTION

Infective endocarditis (IE) due to methicillin-resistant Staphylococcus aureus (MRSA) is characterized by frequent treatment failure to first-line agents and high mortality, necessitating use of alternative management strategies. Ceftaroline fosamil (CPT) is a cephalosporin antibiotic with activity against MRSA but without regulatory approval for the indication of IE. This study describes clinical experience with CPT-based regimens utilized in MRSA-IE.

METHODS

This is a retrospective, observational, descriptive analysis of patients from two major urban medical centers in Detroit, Michigan from 2011 to 2023. Included adult patients (≥ 18 years) had ≥ 1 positive blood culture for MRSA, met definitive clinical criteria for IE, and received CPT for ≥ 72 h. The primary outcome was treatment failure, defined as a composite of 30-day all-cause mortality from index culture or failure to improve or resolve infectious signs/symptoms after CPT initiation.

RESULTS

Seventy patients were included. The median (interquartile range [IQR]) age was 51 (34-63) years and 45.7% were male. Persons with injection drug use (PWID) made up 55.7% of the cohort and right-sided IE was the most prevalent subtype (50.0%). CPT was frequently employed second-line or later, often in combination with vancomycin (10.0%) or daptomycin (72.9%). Overall, 31.4% experienced treatment failure and 30-day all-cause mortality occurred in 15.7%.

CONCLUSIONS

These findings illustrate the challenges posed by MRSA-IE, including frequent treatment failures, and highlight the utilization of CPT as salvage therapy. Comparative studies are needed to more clearly define its role in MRSA-IE.

Late-Term Outcomes of Surgical Treatment of Infective Endocarditis

Background: This study aims to evaluate the long-term outcomes of surgical interventions in patients with infective endocarditis (IE) who underwent surgical treatment and to determine the treatment approach for new patients. Patients and Methods: We retrospectively examined the long-term results of patients who underwent surgical treatment for IE between 2007 and 2017. The evaluation included late-term outcomes of IE surgery, surgical procedures, complications, the postoperative period, and clinical findings. Results: The study included 20 patients (12 male, 8 female) with a mean age of 45.1 ± 17.25. The most common cardiac risk factors for endocarditis development were the presence of prosthetic valves and heart valve disease. In addition, non-cardiac risk factors included chronic renal failure, systemic lupus erythematosus, and pemphigus vulgaris. Preoperative and postoperative laboratory findings were compared with in terms of morbidity and mortality, revealing no significant differences. The most prevalent preoperative laboratory findings were anemia (100%), elevated CRP (100%), and leukocytosis (50%). Anemia persisted as the most common laboratory finding in the postoperative evaluation. Conclusion: Our study identified comorbid chronic medical conditions, neurological complications because of IE, postoperative impaired left ventricular function, and treatment strategies such as monotherapy as poor prognostic factors in patients who underwent surgical treatment for IE. The management of IE is observed to be complex in the presence of comorbidities and complications, adversely affecting both survival and quality of life.

Clinicomicrobiological risk factors for infective endocarditis in viridans group streptococci bacteraemia

BACKGROUND

When to perform echocardiography to rule out infective endocarditis (IE) in patients with viridans group streptococci (VGS) bloodstream infections (BSIs) is unclear.

OBJECTIVES

We aimed to identify independent risk factors for IE in patients with VGS BSI.

METHODS

This retrospective study conducted at Seoul National University Hospital from January 2013 to December 2022 involved patients with VGS and nutritionally variant streptococcal BSI, excluding single positive blood cultures and polymicrobial BSI cases. Independent risk factors were identified by multivariate logistic regression and sensitivity analyses according to echocardiography results, VGS species or the inclusion of possible IE cases.

RESULTS

Of 845 VGS BSI cases, 349 were analysed and 86 IE cases were identified (24.6%). In the multivariate analysis, heart valve disease [adjusted odds ratio (aOR), 14.14, 95% CI, 6.14-32.58; P < 0.001], persistent bacteraemia (aOR, 5.12, 95% CI, 2.03-12.94; P = 0.001), age (per year, aOR, 0.98; 95% CI, 0.96-1.00; P = 0.015), solid cancer (aOR, 0.26; 95% CI, 0.13-0.53; P < 0.001) and haematologic malignancy (aOR, 0.04; 95% CI, 0.01-0.41; P = 0.006) were independently associated with IE. Sensitivity analyses yielded consistent results; also, infection by a member of the mitis group was independent risk factor for IE (aOR, 6.50; 95% CI, 2.87-14.68; P < 0.001).

CONCLUSIONS

Younger age, heart valve disease, persistent bacteraemia, absence of underlying malignancy and BSI by a member of the mitis group were independent risk factors for IE in patients with VGS BSI. Echocardiographic evaluation could be prudently considered based on these clinicomicrobiological risk factors.

Unexpected Infective Endocarditis: Towards a New Alert for Clinicians

Despite the clear indications and worldwide application of specific guidelines, the recognition of Infective Endocarditis (IE) may be challenging in day-to-day clinical practice. Significant changes in the epidemiological and clinical profile of IE have been observed, including variations in the populations at risk and an increased incidence in subjects without at-risk cardiac disease. Emergent at-risk populations for IE particularly include immunocompromised patients with a comorbidity burden (e.g., cancer, diabetes, dialysis), requiring long-term central venous catheters or recurrent healthcare interventions. In addition, healthy subjects, such as skin-contact athletes or those with piercing implants, may be exposed to the transmission of highly virulent bacteria (through the skin or mucous), determining endothelial lesions and subsequent IE, despite the absence of pre-existing at-risk cardiac disease. Emergent at-risk populations and clinical presentation changes may subvert the conventional paradigm of IE toward an unexpected clinical scenario. Owing to its unusual clinical context, IE might be overlooked, resulting in a challenging diagnosis and delayed treatment. This review, supported by a series of clinical cases, analyzed the subtle and deceptive phenotypes subtending the complex syndrome of unexpected IE. The awareness of an unexpected clinical course should alert clinicians to also consider IE diagnosis in patients with atypical features, enhancing vigilance for preventive measures in an emergent at-risk population untargeted by conventional workflows.

Semisynthetic guanidino lipoglycopeptides with potent in vitro and in vivo antibacterial activity

Gram-positive bacterial infections present a major clinical challenge, with methicillin- and vancomycin-resistant strains continuing to be a cause for concern. In recent years, semisynthetic vancomycin derivatives have been developed to overcome this problem as exemplified by the clinically used telavancin, which exhibits increased antibacterial potency but has also raised toxicity concerns. Thus, glycopeptide antibiotics with enhanced antibacterial activities and improved safety profiles are still necessary. We describe the development of a class of highly potent semisynthetic glycopeptide antibiotics, the guanidino lipoglycopeptides, which contain a positively charged guanidino moiety bearing a variable lipid group. These glycopeptides exhibited enhanced in vitro activity against a panel of Gram-positive bacteria including clinically relevant methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant strains, showed minimal toxicity toward eukaryotic cells, and had a low propensity for resistance selection. Mechanistically, guanidino lipoglycopeptides engaged with bacterial cell wall precursor lipid II with a higher binding affinity than vancomycin. Binding to both wild-type d-Ala-d-Ala lipid II and the vancomycin-resistant d-Ala-d-Lac variant was confirmed, providing insight into the enhanced activity of guanidino lipoglycopeptides against vancomycin-resistant isolates. The in vivo efficacy of guanidino lipoglycopeptide EVG7 was evaluated in a S. aureus murine thigh infection model and a 7-day sepsis survival study, both of which demonstrated superiority to vancomycin. Moreover, the minimal to mild kidney effects at supratherapeutic doses of EVG7 indicate an improved therapeutic safety profile compared with vancomycin. These findings position guanidino lipoglycopeptides as candidates for further development as antibacterial agents for the treatment of clinically relevant multidrug-resistant Gram-positive infections.

Low rates of complications and β-lactam resistance in viridans group streptococci bloodstream infection among cancer patients receiving chemotherapy

BACKGROUND

Viridans group streptococci (VGS) bloodstream infection (BSI) frequently occurs in cancer patients receiving chemotherapy, and is associated with infective endocarditis (IE) in up to 20% of cases in the general population.

OBJECTIVES

In cancer patients receiving chemotherapy with VGS BSI, we aimed to: (i) determine the incidence of infective complications including IE, (ii) assess the utility of echocardiography in this patient population, (iii) determine the duration and type of antimicrobial therapy received for monomicrobial infections, and (iv) determine the evolution of antimicrobial resistance.

METHODS

VGS BSIs (excluding Streptococcus pneumoniae and Streptococcus pseudopneumoniae) in cancer patients receiving chemotherapy were identified from a statewide public pathology database between 2013 and 2022 at our tertiary centre. Medical records were accessed for clinical, microbiological and radiological data.

RESULTS

Of 581 patient episodes screened, 183 episodes involving 171 patients met inclusion criteria. Of these, 51% were bone marrow transplantation (BMT) patients, 40% were non-BMT haematology patients, and 8% were solid organ malignancy patients. The median age was 55 years, and 96% were neutropenic at the time of blood culture collection. A transthoracic echocardiogram was performed for 71% of episodes, and one patient met modified Duke's criteria for definite IE, although this diagnosis was not suspected on clinical grounds. Other complications were uncommon. Benzylpenicillin resistance was rare (2.9%) and did not change over time. Most episodes (75%) were treated with piperacillin/tazobactam. For monomicrobial BSIs, the median antibiotic duration was 5 days (IQR 2-7) post-neutropenia resolution.

CONCLUSIONS

Infective complications and antimicrobial resistance are rare in cancer patients with VGS BSI. This may provide a safe opportunity to limit both investigations (e.g. echocardiogram) and prolonged exposure to broad-spectrum antimicrobials.

Exploring Unusual Cardiac Complications: Chorda Tendinea Rupture and Pulmonary Valve Vegetation in Infective Endocarditis-A Comprehensive Review

Infective endocarditis (IE) is a severe infection of the endocardium, frequently involving heart valves, and is associated with significant morbidity and mortality. At the same time, traditional complications of IE, such as valvular dysfunction and embolic events, are well-documented, and uncommon cardiac manifestations, such as chorda tendinea rupture and pulmonary valve vegetation, present unique diagnostic and management challenges. This comprehensive review explores the pathophysiology, clinical presentation, diagnostic strategies, and management approaches for IE's chorda tendinea rupture and pulmonary valve vegetation. Through a detailed examination of the literature and discussion of clinical scenarios, we highlight the importance of recognizing these rare complications and discuss the implications for clinical practice. Additionally, we identify knowledge gaps and propose areas for future research to enhance further our understanding and management of these unusual cardiac complications in IE. This review aims to provide clinicians with valuable insights to improve patient care and outcomes in the challenging setting of infective endocarditis.

Characteristics associated with occurrence of stroke in patients with infective endocarditis - a retrospective cohort study

BACKGROUND

Stroke is a severe complication of infective endocarditis (IE), associated with high rates of mortality. Data on how IE patients with and without stroke differ may help to improve understanding contributing mechanisms.

METHODS

All patients treated for IE between 2019 and 2021 with and without associated stroke were identified from the medical records of three academic tertiary care hospitals in Germany, all part of Charité - Universitätsmedizin Berlin, Germany. Multivariable logistic regression analyses were performed to identify variables associated with the occurrence of stroke.

RESULTS

The study population consisted of 353 patients diagnosed with IE. Concomitant stroke occurred in 96/353 (27.2%) patients. Acute stroke was independently associated with co-occurring extracerebral arterial embolism [adjusted Odds ratio (aOR = 2.52; 95% confidence interval (CI) 1.35-4.71)], acute liver failure (aOR = 2.62; 95% CI 1.06-6.50), dental focus of infection (aOR = 3.14; 95% CI 1.21-8.12) and left-sided IE (aOR = 28.26; 95% CI 3.59-222.19). Stroke was found less often in IE patients with congenital heart disease (aOR = 0.20; 95% CI 0.04-0.99) and atypical pathogens isolated from blood culture (aOR = 0.31; 95% CI 0.14-0.72).

CONCLUSIONS

Stroke is more likely to occur in individuals with systemic complications affecting other organs, too. Special attention should be addressed to dental status. The low incidence of stroke in patients with congenital heart disease may reflect awareness and prophylactic measures.

Mortality patterns in older adults with infective endocarditis in the US: A retrospective analysis

BACKGROUND

Infective Endocarditis (IE) has become a significant cause of morbidity and mortality over the last two decades. Despite management advancements, mortality trends in the USA's geriatric population are unexplored. The aim of this study was to assess the trends and regional differences in IE related mortality among geriatric patients in the USA.

METHODS

We analyzed death certificates sourced from the CDC WONDER database spanning 1999 to 2020. The research targeted individuals aged 65 and older. Age-adjusted mortality rates (AAMRs) per 100,000 and annual percent change (APC), along with 95% CI, were calculated through joinpoint regression analysis.

RESULTS

From 1999 to 2020, infective endocarditis caused 222,573 deaths, showing a declining trend (APC: -0.8361). Males had higher AAMR (26.8) than females (22.2). NH White had the highest AAMR (25.8), followed by NH American Indians or Alaska Natives (19.6). Geographically, the Midwest had the highest AAMR (27.4), followed by the Northeast (25.8). Rural areas consistently had higher AAMRs (26.6) than urban areas (23.6), while 80.16% of deaths occurring in urban settings. North Dakota, Nebraska, and Montana had the highest state AAMRs, approximately double than the states with the lowest mortality rates: Mississippi, Hawaii, California, and Massachusetts. Those aged 85 and above accounted for 42.9% of deaths.

CONCLUSION

IE mortality exhibited a clear pattern: rising till 2004, declining from 2004 to 2018, and increasing again till 2020. Key risk factors were male gender, Midwest residence, NH White ethnicity, and age ≥85.Targeted interventions are essential to reduce IE mortality, especially among vulnerable older populations.

Beyond the acute phase: a comprehensive literature review of long-term sequelae resulting from infectious diseases

Infectious diseases have consistently served as pivotal influences on numerous civilizations, inducing morbidity, mortality, and consequently redirecting the course of history. Their impact extends far beyond the acute phase, characterized by the majority of symptom presentations, to a multitude of adverse events and sequelae that follow viral, parasitic, fungal, or bacterial infections. In this context, myriad sequelae related to various infectious diseases have been identified, spanning short to long-term durations. Although these sequelae are known to affect thousands of individuals individually, a comprehensive evaluation of all potential long-term effects of infectious diseases has yet to be undertaken. We present a comprehensive literature review delineating the primary sequelae attributable to major infectious diseases, categorized by systems, symptoms, and duration. This compilation serves as a crucial resource, illuminating the long-term ramifications of infectious diseases for healthcare professionals worldwide. Moreover, this review highlights the substantial burden that these sequelae impose on global health and economies, a facet often overshadowed by the predominant focus on the acute phase. Patients are frequently discharged following the resolution of the acute phase, with minimal long-term follow-up to comprehend and address potential sequelae. This emphasizes the pressing need for sustained vigilance, thorough patient monitoring, strategic health management, and rigorous research to understand and mitigate the lasting economic and health impacts of infectious diseases more fully.

Massive septic pulmonary embolism from infective endocarditis obstructing the right pulmonary artery: a case report

Infective endocarditis (IE) is a relatively rare but life-threatening condition with potential complications such as valve dysfunction, abscess formation, development of penetrating lesions and embolization of septic material. In this case report, we describe the case of a 56-year-old with IE involving the tricuspid valve and resulting in near total occlusion of the right pulmonary artery due to embolization of a massive piece of septic material. While embolization of septic material is well documented, associated occlusion of the right pulmonary artery is rare.

Glomerulonephritis Associated With Infected Cardiac Pacemaker Lead Mimics Infective Endocarditis-Associated Glomerulonephritis With Resolution After Lead Removal: A Case Report and Literature Review

The incidence of cardiac pacemaker lead infections is increasing due to the rise in cardiac implantable device use. These infections mimic infective endocarditis (IE) and cause a variety of complications. However, there is a scarcity of knowledge regarding glomerulonephritis (GN) resulting from cardiac pacemaker-lead infections. This report describes a 71-year-old female who presented with GN associated with a cardiac pacemaker-lead infection. The patient was successfully treated with intravenous (IV) antibiotics, IV steroids, and early surgical removal of the cardiac pacemaker lead, resulting in the resolution of GN. Current guidelines do not address cardiac pacemaker lead infection-associated GN as an indication for lead removal. Given the success of our treatment approach and the rising incidence of cardiac pacemaker infections, we suggest the consideration of early surgical removal of the cardiac lead, in conjunction with antibiotics and steroids, for the treatment of cardiac lead infection associated with GN. Further research is necessary to determine the prevalence and optimal management of this complication.

Kocuria Species Infections in Humans-A Narrative Review

Kocuria species are catalase-positive and coagulase-negative Gram-positive coccoid bacteria that belong to the family Micrococcaceae, order Actinomycetales, and class Actinobacteria. Even though they may be relatively rare, they have been increasingly reported as the causes of human infections lately. The present study aims to review all published cases of Kocuria spp. infections in humans reporting data on epidemiology, microbiology, antimicrobial susceptibility, antimicrobial treatment, and mortality. A narrative review was performed based on a search of Pubmed and Scopus databases in the literature. In total, 73 studies provided data on 102 patients with Kocuria spp. infections. The mean age of patients was 47 years, and 68.3% were male. The most common types of infection were bacteremia (36.3%), skin and soft tissue infection (18.6%), endophthalmitis (15.7%), infective endocarditis (13.7%), and peritonitis (11.8%), most commonly peritoneal-dialysis-associated. The most frequently isolated species was K. kristinae (46.1%), and antimicrobial resistance was lower for vancomycin (7%) and tetracyclines (6.7%). Vancomycin (47%), cephalosporins (39.6%), and quinolones (36.6%) were the most commonly used antimicrobials. The empirical antimicrobial treatment of Kocuria spp. infections should include vancomycin as long as antimicrobial susceptibility results are pending. The infection outcome mainly depends on the type of infection and is higher for infective endocarditis. Endophthalmitis is associated with increased rates of low visual acuity after treatment.

Diagnostic Work-Up in Patients with Nonbacterial Thrombotic Endocarditis

Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis that occurs in patients with predisposing conditions, including malignancies, autoimmune diseases (particularly antiphospholipid antibody syndrome, which accounts for the majority of lupus-associated cases), and coagulation disturbances for which the correlation with classical determinants is unclear. The condition is commonly referred to as "marantic", "verrucous", or Libman-Sacks endocarditis, although these are not synonymous, representing clinical-pathological nuances. The clinical presentation of NBTE involves embolic events, while local valvular complications, generally regurgitation, are typically less frequent and milder compared to infective forms of endocarditis. In the past, the diagnosis of NBTE relied on post mortem examinations, while at present, the diagnosis is primarily based on echocardiography, with the priority of excluding infective endocarditis through comprehensive microbiological and serological tests. As in other forms of endocarditis, besides pathology, transesophageal echocardiography remains the diagnostic standard, while other imaging techniques hold promise as adjunctive tools for early diagnosis and differentiation from infective vegetations. These include cardiac MRI and 18FDG-PET/CT, which already represents a major diagnostic criterion of infective endocarditis in specific settings. We will herein provide a comprehensive review of the current knowledge on the clinics and therapeutics of NBTE, with a specific focus on the diagnostic tools.

Contemporary Clinical Profile of Left-Sided Native Valve Infective Endocarditis: Influence of the Causative Microorganism

Studies focused on the clinical profile of native valve endocarditis are scarce and outdated. In addition, none of them analyzed differences depending on the causative microorganism. Our objectives are to describe the clinical profile at admission of patients with left-sided native valve infective endocarditis in a contemporary wide series of patients and to compare them among the most frequent etiologies. To do so, we conducted a prospective, observational cohort study including 569 patients with native left-sided endocarditis enrolled from 2006 to 2019. We describe the modes of presentation and the symptoms and signs at admission of these patients and compare them among the five more frequent microbiological etiologies. Coagulase-negative Staphylococci and Enterococci endocarditis patients were the oldest (71 ± 11 years), and episodes caused by Streptococci viridans were less frequently nosocomial (4%). The neurologic, cutaneous or renal modes of presentation were more typical in Staphylococcus aureus endocarditis (28%, p = 0.002), the wasting syndrome of Streptococcus viridans (49%, p < 0.001), and the cardiac in Coagulase-negative Staphylococci, Enterococci and unidentified microorganism endocarditis (45%, 49% and 56%, p < 0.001). The clinical signs agreed with the mode of presentation. In conclusion, the modes of presentation and the clinical picture at admission were tightly associated with the causative microorganism in patients with left-sided native valve endocarditis.

Infective Endocarditis among Pediatric Patients with Prosthetic Valves and Cardiac Devices: A Review and Update of Recent Emerging Diagnostic and Management Strategies

Infective endocarditis (IE) is a disease of the endocardium, which leads to the appearance of vegetation on the valves, cardiac structures, or, potentially, vascular endothelium of the heart. The risk of IE can be increased more than 140 times by congenital heart disease (50-59% of all IE), particularly if cyanotic. An increase in mortality may result from IE in patients with a complex cardiac pathology or patients with an implanted prosthetic material, most frequently conduits in a pulmonary position. Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication representing 10% of all cases of endocarditis. Common signs of presentation are often fever and chills; redness and swelling at the pocket of the pacemaker, including the erosion and exteriorization of the device; and life-threatening sepsis. The use of intracardiac echocardiography for the diagnosis of IE is an innovative method. This may be needed, especially in older children undergoing complex cardiac surgery, when transthoracic echocardiography (TTE) and transesophageal echocardiography (TOE) failed to provide a reliable diagnosis. The 2018 European Heart Rhythm Association (EHRA) experts' consensus statement on transvenous lead extraction recommends complete device removal and antimicrobial therapy for any device-related infection, including CIED-IE. The most detected microorganism was Staphylococcus Aureus. In addition, cardiac surgery and interventional cardiology associated with the placement of prostheses or conduits may increase the risk of IE up to 1.6% for Melody valve implantation. Our manuscript presents a comprehensive review of infective endocarditis associated with cardiac devices and prostheses in the pediatric population, including recent advances in diagnosis and management.

Human Serum Supplementation Promotes Streptococcus mitis Growth and Induces Specific Transcriptomic Responses

Streptococcus mitis is a normal member of the human oral microbiota and a leading opportunistic pathogen causing infective endocarditis (IE). Despite the complex interactions between S. mitis and the human host, understanding of S. mitis physiology and its mechanisms of adaptation to host-associated environments is inadequate, especially compared with other IE bacterial pathogens. This study reports the growth-promoting effects of human serum on S. mitis and other pathogenic streptococci, including S. oralis, S. pneumoniae, and S. agalactiae. Using transcriptomic analyses, we identified that, with the addition of human serum, S. mitis downregulates uptake systems for metal ions and sugars, fatty acid biosynthetic genes, and genes involved in stress response and other processes related with growth and replication. S. mitis upregulates uptake systems for amino acids and short peptides in response to human serum. Zinc availability and environmental signals sensed by the induced short peptide binding proteins were not sufficient to confer the growth-promoting effects. More investigation is required to establish the mechanism for growth promotion. Overall, our study contributes to the fundamental understanding of S. mitis physiology under host-associated conditions. IMPORTANCE S. mitis is exposed to human serum components during commensalism in the human mouth and bloodstream pathogenesis. However, the physiological effects of serum components on this bacterium remain unclear. Using transcriptomic analyses, S. mitis biological processes that respond to the presence of human serum were revealed, improving the fundamental understanding of S. mitis physiology in human host conditions.

An Unexpected Outcome of Streptococcus sanguinis Endocarditis Associated With Orthodontic Bracing in a Young Healthy Patient

We present a case of Streptococcus sanguinis endocarditis in a 26-year-old female following orthodontic bracing. The rarity and debilitating consequences of endocarditis caused by Streptococcus sanguinis are elaborated. The patient exhibited severe regurgitation with the eccentric posteriorly directed flow, leading to significant cardiac strain, further accentuated by systolic flow reversal in the right superior pulmonary vein. Surgical intervention, including mitral valve replacement, was crucial in addressing the underlying infection, restoring valve function, and preventing further complications. However, a second mitral valve replacement was performed due to recurrent bioprosthesis endocarditis. This case underscores the unique challenges of Streptococcus sanguinis endocarditis, emphasizing the need for a multidisciplinary approach and individualized decision-making to optimize patient care.

Transesophageal Echocardiography vs. Transthoracic Echocardiography for Methicillin-Sensitive Staphylococcus aureus and Methicillin-Resistant Staphylococcus aureus Endocarditis

Infective endocarditis is an infection of the inner layers of the heart, seen often in intravenous drug users and patients with valvular lesions or prosthetic heart valves. This entity has high mortality and morbidity. The most common causative microorganism is Staphylococcus aureus. In this comprehensive literature review, we focused on both Staphylococcus aureus infections, i.e., methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) endocarditis, demographics, use of transthoracic echocardiogram and/or transesophageal echocardiogram for diagnostics, and treatments. Although clinical criteria are relevant, transesophageal echocardiogram plays a vital role in establishing and identifying the presence of infective endocarditis and its local complications, with higher sensitivity in patients with prosthetic valves. The antibiotic selection posed a great challenge for clinicians due to antibiotic resistance and the aggressive nature of Staphylococcus aureus. Early diagnosis of infective endocarditis, when suspected, and effective management by a multispecialty team can improve the outcome for the patients.

The role of early defervescence in ruling out infective endocarditis: a cohort study

OBJECTIVES

To evaluate the role of defervescence within 4 days from antibiotic treatment initiation in ruling out infective endocarditis (IE) among patients suspected of such diagnosis.

METHODS

This study was conducted at the Lausanne University Hospital, Lausanne, Switzerland (01.2014 to 06.2022). All patients with suspected IE being febrile upon presentation were included. IE was classified according to the modified Duke criteria proposed by the 2015 European Society of Cardiology guidelines, before or after applying the criterion "resolution of symptoms suggesting IE within 4 days of introduction of antibiotic therapy" based solely on early defervescence.

RESULTS

Among 1022 episodes with suspected IE, 332 (37%) had IE according to Endocarditis-Team evaluation; 248 were classified by clinical Duke criteria as definite and 84 as possible IE. The rate of defervescence within 4 days from antibiotic treatment initiation was similar (P 0.547) among episodes without (606/690; 88%) and those with IE (287/332; 86%); among episodes classified as definite and possible IE by clinical Duke criteria, 211/248 (85%) and 76/84 (90%), respectively, defervesced within 4 days from antibiotic treatment initiation. By using early defervescence as a rejection criterion, the 76 episodes with final IE diagnosis classified as possible by clinical criteria could be reclassified as rejected.

CONCLUSIONS

The majority of IE episodes defervesced within 4 days from antibiotic treatment initiation, thus early defervescence should not be used to rule out the diagnosis of IE.

The Use of AngioVac in a Patient With Severe Infective Endocarditis Where Open Heart Surgery Is Contraindicated: A Case Report

Infectious endocarditis of the tricuspid valve (TV) is a common complication of intravenous (IV) drug use. Endocarditis caused by viridans streptococci can lead to heart valve vegetations, which may be life-threatening due to the potential for embolism and obstruction. The management of large valvular vegetations is often difficult due to the risks involved with open heart surgery, especially in patients with comorbid conditions. The AngioVac device (AngioDynamics Inc., Latham, NY) has been shown in rare cases to be effective at debulking vegetations without the need for invasive surgery. We present a 45-year-old male with a history of intravenous heroin use disorder, hepatitis C, spinal abscesses, and chronic anemia who experienced worsening shortness of breath, generalized weakness, bilateral lower extremity edema, dysuria with dark urine, and blood on toilet paper. Workup revealed a 4.39 × 4.35 cm tricuspid valve vegetation, severe tricuspid regurgitation (TR), acute renal failure, acute on chronic anemia, and thrombocytopenia from sepsis-induced disseminated intravascular coagulation (DIC). AngioVac was used to aspirate the vegetation and effectively reduced the size to 3.75 × 2.31 cm. Follow-up blood cultures revealed no growth after five days. This is the largest documented tricuspid valve vegetation with a successful implementation of the AngioVac to date. This therapy, in conjunction with intravenous antibiotics and hemodialysis, successfully sterilized the vegetation, prevented worsening presentation, and averted life-threatening complications, although severe tricuspid regurgitation persisted. Based on the findings of this case, the AngioVac device is a safe and effective treatment option for tricuspid valve endocarditis patients with large vegetation and severe comorbidities, which contraindicate open heart surgery.

Infectious endocarditis caused by Bartonella henselae associated with infected pets: two case reports

BACKGROUND

Blood culture-negative infective endocarditis is a potentially severe disease that can be associated with infectious agents such as Bartonella spp., Coxiella burnetti, Tropheryma whipplei, and some fungi.

CASE PRESENTATION

Reported here are two cases of blood culture-negative infective endocarditis in patients with severe aortic and mitral regurgitation in Brazil; the first case is a 47-year-old white man and the second is a 62-year-old white woman. Bartonella henselae deoxyribonucleic acid was detectable in the blood samples and cardiac valve with vegetation paraffin-fixed tissue samples. Additionally, an investigation was carried out on patients' pets, within the context of One Health, and serum samples collected from cats and dogs were reactive by indirect immunofluorescence assay.

CONCLUSIONS

Even though the frequency of bartonellosis in Brazil is unknown, physicians should be aware of the possibility of blood culture-negative infective endocarditis caused by Bartonella, particularly in patients with weight loss, kidney changes, and epidemiological history for domestic animals.

Contemporary Review of Multi-Modality Cardiac Imaging Evaluation of Infective Endocarditis

Infective endocarditis (IE) remains to be a heterogeneous disease with high morbidity and mortality rates, which can affect native valves, prosthetic valves, and intra-cardiac devices, in addition to causing systemic complications. The combination of clinical, laboratory, and cardiac imaging evaluation is critical for early diagnosis and risk stratification of IE. This can facilitate timely medical and surgical management to improve patient outcomes. Key imaging findings for IE include vegetations, valve perforation, prosthetic valve dehiscence, pseudoaneurysms, abscesses, and fistulae. Transthoracic echocardiography continues to be the first-line imaging modality of choice, while transesophageal echocardiography subsequently provides an improved structural assessment and characterization of lesions to facilitate management decision in IE. Recent advances in other imaging modalities, especially cardiac computed tomography and 18F-fluorodeox-yglucose positron emission tomography, and to a lesser extent cardiac magnetic resonance imaging and other nuclear imaging techniques, have demonstrated important roles in providing complementary IE diagnostic and prognostic information. This review aims to discuss the individual and integrated utilities of contemporary multi-modality cardiac imaging for the assessment and treatment guidance of IE.

The Evolving Trends in Infective Endocarditis and Determinants of Mortality: a 10-year Experience From a Tertiary Care Epicenter

The epidemiology of infective endocarditis (IE) continues to evolve in areas affected by the opioid epidemic. Understanding the demographics of the disease allows us to better tailor therapy towards this at-risk population. This was an observational study of adults (age ≥ 18) admitted to the University of Kentucky hospital with IE between January 2009 and December 2018. 1,255 patients were included in the final analysis. The mean age was 42 years, 45% were female and injection drug use was seen in 66% of patients. On multivariable analysis, higher Charlson comorbidity indices, left sided, and multivalve involvement were associated with increased mortality, whereas surgical intervention demonstrated a trend towards lower mortality. Our results highlight the alarming increase in injection drug use related IE and the high mortality rates despite therapeutic advances. Patients with left sided IE, multivalve involvement and a higher Charlson comorbidity index had decreased survival.

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.

Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis-Model of Care

Infective endocarditis (IE) is a serious infectious disease with significant mortality and morbidity placing a burden on healthcare systems. Outpatient antimicrobial therapy in selected patients has been shown to be safe and beneficial to both patients and the healthcare system. In this article, we review the literature on the model of care for outpatient parenteral antimicrobial therapy in infective endocarditis and propose that systems of care be developed based on local resources and all patients admitted with infective endocarditis be screened appropriately for outpatient antimicrobial therapy.

Native and Prosthetic Simultaneously Double Valve Infective Endocarditis with Enterococcus faecalis-Case-Based Review

Infective endocarditis is a severe infective heart disease, commonly involving native or prosthetic valves. It frequently presents with univalvular involvement and simultaneous double valve or multivalvular involvement is rarely described. The third leading cause of infective endocarditis worldwide is Enterococcus faecalis, which is associated with high mortality rates despite important advances in antimicrobial therapy. It develops secondary to enterococcal bacteremia, with its origin from the gastrointestinal or genitourinary tract and predominantly affecting the elderly population with multiple comorbidities. Clinical presentation is usually less typical, and the treatment is challenging. It can be marked by antibiotic resistance, side effects, and subsequent complications. Surgical treatment can be considered if deemed appropriate. To the best of our knowledge, we present the first case-based narrative review of Enterococcus faecalis double valve endocarditis involving both the aortic native and prosthetic mitral valve, highlighting the clinical characteristics, treatment, and complications of this condition.

Trends in the incidence and mortality of infective endocarditis in high-income countries between 1990 and 2019

BACKGROUND

Infective endocarditis (IE) remains a life-threatening disease with high morbidity and mortality.

OBJECTIVES

To describe temporal trends in IE incidence, mortality and survival over the last 30 years.

METHODS

Nineteen high-income countries (the 'EU 15+') were included. Age-standardised and sex-stratified incidence rates (ASIRs) and mortality rates (ASMRs) for IE were extracted from the Global Burden of Disease (GBD) database between 1990 and 2019, and mortality to incidence ratios (ASMIRs) were calculated. Trends were analysed using Joinpoint regression analysis.

RESULTS

ASIRs were higher in males than females and increased in both sexes in all countries between 1990 and 2019. A recent steep rise in ASIRs was noted in several countries including the UK, the USA and Germany. ASMRs increased for both sexes in all countries except Finland and Austria. The largest increase in ASMR was observed in females in Italy (+246%). ASMIRs were generally higher in females compared to males, with large increases in ASMIRs (indicating worsening survival) at the end of the 20th century, but more recent stabilisation or decline across the study cohort.

CONCLUSIONS

While the incidence and mortality of IE have increased over the last 30 years, recent data suggest that these trends have plateaued or reversed in most countries studied. However, a recent surge in incidence in several countries (including the USA and UK) is of concern, while unfavourable outcomes in females also merit attention. More encouragingly, this analysis provides the first indication of improving IE survival at population level, supporting recent advances in diagnosis and treatment.

Molecular Imaging of Valvular Diseases and Cardiac Device Infection

The use of positron emission tomography imaging with 18F-fluorodeoxyglucose in the diagnostic workup of patients with suspected prosthetic valve endocarditis and cardiac device infection (implantable electronic device and left ventricular assist device) is gaining momentum in clinical practice. However, in the absence of prospective randomized trials, guideline recommendations about 18F-fluorodeoxyglucose positron emission tomography in this setting are currently largely based on expert opinion. Measurement of aortic valve microcalcification occurring as a healing response to valvular inflammation using 18F-sodium fluoride positron emission tomography represents another promising clinical approach, which is associated with both the risk of native valve stenosis progression and bioprosthetic valve degeneration in research trials. In this review, we consider the role of molecular imaging in cardiac valvular diseases, including aortic stenosis and valvular endocarditis, as well as cardiac device infections.

Endocarditis: Who Is Particularly at Risk and Why? Ten Years Analysis of Risk Factors for In-hospital Mortality in Infective Endocarditis

BACKGROUND

Endocarditis is continuously increasing. Evidence exist that the prognosis is adversely affected by the extent of the disease. We looked at risk factors influencing in-hospital mortality (HM).

PATIENTS AND METHODS

Between 2010 and 2019, 484 patients, 338 males (69.8%) with mean age of 66.1 years were operated on because of proven endocarditis. In a retrospective study, a risk factor analysis was performed.

RESULTS

Overall HM was 30.17%. Significant influencing factors (odds ratios [ORs] or p-value) for HM were: age (p = 0.004), logistic EuroSCORE (p< 0.001), gender (OR = 1.64), dialysis (OR = 2.64), hepatic insufficiency (OR = 2.17), reoperation (OR = 1.77), previously implanted valve (OR = 1.97), periannular abscess (OR = 9.26), sepsis on admission (OR = 12.88), and number of involved valves (OR = 1.96). Development of a sepsis and HM was significantly lower if Streptococcus mitis was the main pathogen in contrast to other bacteria (p< 0.001). Staphylococcus aureus was significantly more often found in patients with a previously implanted prosthesis (p = 0.03) and in recurrent endocarditis (p = 0.02), while it significantly more often showed peripheral septic emboli than the other pathogens (p< 0.001).

CONCLUSION

Endocarditis remains life-threatening. Severe comorbidities adversely affected early outcome, particularly, in presence of periannular abscesses. Patients with suspected endocarditis should be admitted to a specialized heart center as early as possible. Streptococcus mitis appears to be less virulent than S. aureus. Further studies are required to verify these findings.

Readmission with infective endocarditis within 90 days following transcatheter aortic valve implantation

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) continues to be the most common modality of treating aortic stenosis in the United States. While infective endocarditis (IE) and its outcomes have been well documented after surgical aortic valve replacement, the incidence and outcomes of early IE after TAVI have not been well described.

METHODS

All patients who underwent TAVI from 2012 through 2018 were identified using the National Readmission Database. Among them, patients who underwent TAVI at the index admission and readmitted within 90 days were included. Patients who died or had IE during the index admission were excluded. Clinical outcomes were compared between patients readmitted with IE (IE group) and those without (non-IE group).

RESULTS

A total of 168,283 patients were readmitted to a hospital within 90 days after TAVI. The median age of the IE group and non-IE group were 81 and 82 years old, respectively (p = 0.21). Of those, 525 (0.3%) were readmitted with IE. The median time from TAVI to readmission was 20 days. During readmissions, 11.6% of the IE group died while only 3.15% of the non-IE group experienced death (p < 0.001). The most common causative organism of IE was enterococcus (22.1%). Multivariable analysis revealed that congestive heart failure, cerebrovascular disease, dialysis, concomitant valve disease, Medicaid, and discharge to a facility were independently associated with readmission with IE within 90 days.

CONCLUSION

The incidence of readmission with IE is low after TAVI. However, the mortality was markedly high during readmissions. Surgical intervention was rarely performed for IE during the first admission. Enterococcus was the most common organism observed in IE after TAVI.

DISCLOSURE

IS receives institutional research support from Abbott, Atricure, cryolife, and Medtronic. None related to this manuscript.

CLINICAL TRIAL REGISTRATION

Not applicable.

A rare association of invasive infective endocarditis due to Abiotrophia defectiva with ventricular septal defect and recurrent Henoch-Schonlein purpura in a child

BACKGROUND

Henoch-Schonlein purpura is the most common vasculitis in childhood, usually triggered by an upper respiratory tract infection and rarely observed in infective endocarditis patients. Abiotrophia defectiva is a rare causative agent of infective endocarditis associated with pre-existing heart disease, immunocompromised and prosthetic valves. Dental procedures are also a common predisposing factor.

CASE PRESENTATION

We present the first pediatric congenital heart disease case of infective endocarditis caused by Abiotrophia defectiva combined with recurrent Henoch-Schonlein purpura. A 10-year-old girl with uncorrected congenital heart defects and Henoch-Schonlein purpura developed a purple petechial rash again. Transthoracic echocardiography evaluation revealed multiple irregular vegetations on the right ventricular side of the ventricular septal defect and on the tricuspid valve leaflets. Blood cultures grew Abiotrophia defectiva. The girl received cardiac surgery for vegetation resection as well as congenital heart defect correction and tricuspid valve replacement. Five months after the surgery, the patient was in satisfactory condition without any signs of endocarditis or valve insufficiency and her purpuric rash disappeared.

CONCLUSIONS

The coexistence of recurrent Henoch-Schonlein purpura and infective endocarditis is possible. Abiotrophia defectiva belongs to the streptococcus with a high virulence. In addition, cardiovascular surgery is often required for pediatric infective endocarditis associated with Abiotrophia defectiva, and bioprosthetic valve replacement is considered feasible for irreparable tricuspid valve in children.

Tricuspid Valve Endocarditis in Four Patients with Unrepaired Restrictive Perimembranous Ventricular Septal Defects

Congenital heart disease (CHD) is the most common predisposing factor for pediatric infective endocarditis (IE). Although patients with unrepaired ventricular septal defects (VSDs) are at greater risk of IE than those without CHD, the American Heart Association (AHA) considers VSDs to be relatively low risk and therefore does not recommend antibiotic prophylaxis against IE. Even among patients with VSDs who develop IE, current AHA and European Society for Cardiology (ESC) guidelines do not recommend surgical VSD closure, despite the potential for a second IE event. We present a case series of four children with small, restrictive, perimembranous VSDs who developed tricuspid valve (TV) IE. All four experienced delayed diagnosis and secondary complications, including three with septic pulmonary emboli. All four patients ultimately underwent surgical VSD closure. These cases highlight the importance of recognizing IE as a possible cause of prolonged fever in children, even among those with even 'low-risk' CHD. The cases also draw attention to the potential benefits of VSD closure in patients who develop IE.

Native valve, prosthetic valve, and cardiac device-related infective endocarditis: A review and update on current innovative diagnostic and therapeutic strategies

Infective endocarditis (IE) is a life-threatening microbial infection of native and prosthetic heart valves, endocardial surface, and/or indwelling cardiac device. Prevalence of IE is increasing and mortality has not significantly improved despite technological advances. This review provides an updated overview using recent literature on the clinical presentation, diagnosis, imaging, causative pathogens, treatment, and outcomes in native valve, prosthetic valve, and cardiac device-related IE. In addition, the experimental approaches used in IE research to improve the understanding of disease mechanisms and the current diagnostic pipelines are discussed, as well as potential innovative diagnostic and therapeutic strategies. This will ultimately help towards deriving better diagnostic tools and treatments to improve IE patient outcomes.

Aerococcus Urinae Endocarditis: A Case Report and Literature Review

A 75-year-old male, with a past medical history of chronic kidney disease stage 3 (CKD3) and a recent diagnosis of bilateral hydronephrosis and Foley catheter placement, presented to the emergency department for fever. Blood cultures grew Aerococcus urinae. Transthoracic echo (TTE) demonstrated thickened aortic valve leaflets with perforation, multiple echo densities, and severe aortic regurgitation. The patient developed decompensated congestive heart failure and cardiogenic shock. En route to surgery for emergent aortic valve replacement, the patient lost pulse and was resuscitated. The patient was subsequently transferred to the ICU where the family decided to initiate comfort care measures. This case highlights the importance and necessity of the prompt diagnosis and treatment of infective endocarditis and makes the reader aware of uncommon and rare organisms, such as Aerococcus urinae, as potential etiologies.

Infective endocarditis in developing countries: An update

Introduction

Despite advances in diagnostic and treatment, morbidity and mortality due to infective endocarditis (IE) has not decreased. There is a discrepancy in epidemiology of IE between developed and developing countries. Over the last years, increased early detection and consequently prevalence of rheumatic heart disease (RHD) and congenital heart disease (CHD) which are considered predisposing conditions for IE, is noted. Here, we present a review of literature on IE in developing countries.

Methods

We conducted a systematic literature search of IE studies in developing countries through PubMed and Embase. We have divided the studies into two groups: studies published before 2015 (group 1) and studies ≥ 2015 (group 2). The outcome was defined as a difference in epidemiology, microbiology, treatment, and mortality over time. The Scale for Assessment of Narrative Review Articles guidelines was applied.

Findings

In total, 16 studies were included. The total number of IE cases was 1,098 and 1,505 in groups 1 and 2, respectively. We compared 4/7 cohorts from group 1 (n = 789) with 5/9 cohorts from group 2 (n = 636). Six studies were not included in the comparison because they were interacting between the two cohorts. Males predominated in all studies. Rheumatic heart disease was higher in group 1 than in group 2 (42.3% vs. 30.3%, p < 0.001) while for CHD there was no change (17.6% vs. 16.7%, p = 0.672). Streptococci infections was lower in group 1 than group 2 (26.2% vs. 37.7%, p < 0.001). The proportion of Staphylococcus aureus was 15.3% in group 1 and 23.6% in group 2, p < 0.001. Negative blood culture (NBC) was higher in group 1 than in group 2 (42.2% vs. 34.1%, p = 0.002). Patients in group 1 received more surgery than in group 2 (38.8% vs. 28.8%, p < 0.001). Mortality was similar in the two groups (20.9% vs. 22.3%, p = 0.518).

Conclusion

This review shows a scarcity of studies on IE in developing countries. Rheumatic heart disease and congenital heart disease are common predisposing conditions. Other risk factors are prosthetic valves, degenerative valve disease (DVD), intravenous drug use, and human immunodeficiency virus infection. While the proportion of IE cases caused by Streptococcus and Staphylococcus has increased, the number of NBC and patients getting surgery has decreased. Mortality has not changed over time. Timely diagnosis and management of patients with RHD and CHD and comprehensive management of IE are warranted.

Clinical Efficacy of Percutaneous Vegetectomy in Tricuspid and Right-Heart Indwelling Device Infective Endocarditis

Several studies have analyzed the efficacy of AngioVac for percutaneous intracardiac vegetectomy, but impact on surgical candidacy or clinical efficacy for infectious endocarditis (IE) is currently unknown. This is a single-arm, retrospective study on IE vegetectomy with impact on surgical risk scores. Analysis included 32 patients who underwent AngioVac vegetectomy for right heart IE at a single institution. The primary endpoint was improvement in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) scores. Secondary endpoints included technical success, improved leukocytosis, procedural safety, 30-day mortality, and 60-day mortality. Findings demonstrate 90.6% (n = 29) technically successful debulking. There was improvement in mean NSQIP scores from 34.6 to 27.9 ( P = .007). Zero cases of 30-day all-cause mortality. One patient experienced a major post-procedural complication of pneumothorax, a Class D Adverse Event. 20.5% (n = 5) of valvular vegetation patients went on to have surgical tricuspid valve repair. All indwelling intracardiac devices were removed. Findings suggest that percutaneous vegetectomy improves surgical candidacy, as measured by ACS NSQIP scores, in patients with IE and right heart vegetations and is associated with low complication rates.