Critical Questions About Left-Sided Infective Endocarditis

Percutaneous Mechanical Aspiration for Infective Endocarditis: Proceedings From an Inaugural Multidisciplinary Summit and Comprehensive Review

The clinical presentation and epidemiology of infective endocarditis (IE) have evolved over time. While the cornerstones of IE treatment remain antimicrobial therapy and surgery, percutaneous mechanical aspiration (PMA) has emerged as an option for carefully selected patients as a complementary modality, based on retrospective data, case series, and expert experience. In this comprehensive review, we summarize the proceedings from an inaugural summit dedicated to the discussion of PMA in the global management of IE, consisting of experts across multiple disciplines from diverse geographic regions and care environments. After conceptualizing the 3 major roles of PMA as a bridge to decision, destination therapy, and adjunctive therapy, we then review the clinical scenarios in which PMA might be considered by IE subtype. We discuss patient selection, the rationale for intervention, and the most recent evidence for each. Next, we consider PMA for IE in the larger context of our health care system across 3 domains: clinical collaboration, financial considerations, and academic innovation, emphasizing the importance of interdisciplinary teams and cross-organizational partnerships, reimbursement models, and the need for high-quality research. Finally, we outline what we determined to be the most pressing outstanding questions in this space. In doing so, we propose a national consortium to help organize efforts to move this field forward and share our progress in these endeavors to date. PMA for IE has great promise, but significant work remains if we are to fully realize its potential to safely and effectively improve outcomes for modern endocarditis patients.

A nomogram for prediction of early mortality in patients undergoing cardiac surgery for infective endocarditis: a retrospective single-center study

OBJECTIVE

Despite advancements in surgical techniques, operations for infective endocarditis (IE) remain associated with relatively high mortality. The aim of this study was to develop a nomogram model to predict the early postoperative mortality in patients undergoing cardiac surgery for infective endocarditis based on the preoperative clinical features.

METHODS

We retrospectively analyzed the clinical data of 357 patients with IE who underwent surgeries at our center between January 2007 and June 2023. Independent risk factors for early postoperative mortality were identified using univariate and multivariate logistic regression models. Based on these factors, a predictive model was developed and presented in a nomogram. The performance of the nomogram was evaluated through the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA). Internal validation was performed utilizing the bootstrapping method.

RESULTS

The nomogram included nine predictors: age, stroke, pulmonary embolism, albumin level, cardiac function class IV, antibotic use <4weeks, vegetation size ≥1.5 cm, perivalvular abscess and preoperative dialysis. The area under the ROC curve (AUC) of the model was 0.88 (95%CI:0.80-0.96). The calibration plot indicated strong prediction consistency of the nomogram with satisfactory Hosmer-Lemeshow test results (χ2 = 13.490, p = 0.142). Decision curve analysis indicated that the nomogram model provided greater clinical net benefits compared to "operate-all" or "operate-none" strategies.

CONCLUSIONS

The innovative nomogram model offers cardiovascular surgeons a tool to predict the risk of early postoperative mortality in patients undergoing IE operations. This model can serve as a valuable reference for preoperative decision-making and can enhance the clinical outcomes of IE patients.

Broviac Catheter-Related Aortic Valve Infective Endocarditis Complicated With Massive Aortic Regurgitation Requiring Emergency Surgery: A Case Report

Introduction: Broviac catheter is a type of central venous catheter (CVC) used for long-term parenteral nutrition in specific patients, e.g., diagnosed with intestinal failure as short bowel syndrome (SBS). The way of the catheter insertion is conceived to minimalize the risk of infections. However, CVC-related blood stream infections (CVC-BSIs), including infective endocarditis (IE), remain most important complications associated with Broviac catheter. Staphylococcus epidermidis stands out as a prevalent pathogen. The increasing number of CVCs results in an increased incidence of healthcare-associated IE. Complete parenteral treatment is an independent risk that increases the likelihood of IE. Treatment of IE is mainly based on antibiotic therapy, but in certain cases, surgical treatment is needed. Presentation of Case: A 71-year-old female with SBS who had been receiving total parenteral nutrition through the Broviac catheter for several months was admitted in a serious condition with significant weakness, increasing shortness of breath, deteriorating cough, fever, low blood pressure, and heart palpitations. Echocardiography revealed severe aortic valve IE with a large, longitudinal, highly mobile vegetation (up to 40 mm) and massive aortic regurgitation with pulmonary edema. Fast pathogen detection in the patients' blood (S. epidermidis) was obtained using PCR-based multiplex test. Due to life-threatening conditions, emergency surgery with aortic valve replacement was performed. Consistent rehabilitation resulted in good condition achievement. Follow-up echocardiography showed normal function of the aortic valve bioprosthesis. Conclusion: The use of CVC, including Broviac catheter, is associated with an increased risk of infections, including IE. Treatment-resistant severe HF complicating IE requires emergency surgery.

Floppy Mitral Valve/Mitral Valve Prolapse and Manifestations Not Related to Mitral Regurgitation: Time to Search the Dark Side of the Moon

BACKGROUND

Floppy mitral valve/mitral valve prolapse (FMV/MVP) is a complex entity in which several clinical manifestations are not directly related to the severity of mitral regurgitation (MR).

SUMMARY

Patients with FMV/MVP and trivial to mild MR may have exercise intolerance, orthostatic phenomena, syncope/presyncope, chest pain, and ventricular arrhythmias, among others. Several anatomical and pathophysiologic consequences related to the abnormal mitral valve apparatus and to prolapse of the mitral leaflets into the left atrium provide some explanation for these symptoms. Further, it should be emphasized that MVP is a non-specific finding, while FMV (redundant mitral leaflets, elongated/rupture chordae tendineae, annular dilatation) is the central issue in the MVP story.

KEY MESSAGE

The purpose of this review was to highlight the clinical manifestations of FMV/MVP not directly related to the severity of MR and to discuss the pathophysiologic mechanisms contributing to these manifestations.

Recent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios.

Native Aortic Valve Infective Endocarditis Secondary to Community-Acquired Methicillin-Resistant Staphylococcus aureus: A Case Report and Literature Review

Infective endocarditis (IE) refers to a microbial infection affecting either a heart valve or endocardium, resulting in tissue damage and the formation of vegetation. Native aortic valve endocarditis in children is rare and is associated with serious complications related to valvular insufficiency and systemic embolizations. As reports about community-acquired methicillin-resistant Staphylococcus aureus (MRSA) native aortic valve endocarditis in children are very scarce, we report this case along with a literature review about its complications and management. Here, we report the case of a seven-month-old infant who was previously healthy and presented with signs and symptoms of shock and systemic embolizations secondary to native aortic valve IE. His blood culture showed MRSA. He developed aortic valve insufficiency heart failure and multiorgan septic emboli that progressed to fatal refractory multiorgan failure. The management of complicated aortic valve endocarditis in children is challenging and needs a multidisciplinary team approach and prompt intervention.

Detection of pathogens from venous or arterial blood of patients with left-sided infective endocarditis by metagenomic next-generation sequencing: A prospective study

BACKGROUND

Infective endocarditis is a life-threatening uncommon infectious disease, and we aimed to explore the clinical utility of venous or arterial blood-based metagenomic next-generation sequencing (mNGS) approaches to diagnose left-sided infective endocarditis (LSIE).

METHODS

We prospectively studied 79 LSIE patients who received valvular surgery in our hospital. Results of blood culture, valve culture, venous blood-based mNGS, arterial blood-based mNGS, venous blood-based mNGS plus blood culture, and arterial blood-based mNGS plus blood culture were evaluated and compared.

RESULTS

Both venous blood- and arterial blood-based mNGS methods displayed significantly higher positive detection rates than blood culture and valve culture (43.0 %, 49.4 % vs. 32.9 %, 19.0 %; P < 0.001). Strikingly, when combining blood-based mNGS and blood culture, the positive rate could be further improved to more than 60 %. Moreover, we found mNGS LSIE detection was closely associated with preoperative leukocyte (P = 0.027), neutrophil value (P = 0.018), vegetation ≥ 14 mm (P = 0.043), and vegetations in aortic valve (P = 0.048). In addition, we discovered that blood-based mNGS had a superir capacity over blood culture to detect gram-negative bacteria, fungi, Bartonella Quintana, and mixed infections than blood culture.

CONCLUSION

This study indicates that venous blood- and arterial blood-based mNGS displayed high positive rate in the rapid detection of pathogens in high-risk LSIE patients.

Acute mitral regurgitation with and without acute heart failure

Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.

In-hospital Outcomes of Infective Endocarditis from 1978 to 2015: Analysis Through Machine-Learning Techniques

BACKGROUND

Early identification of patients with infective endocarditis (IE) at higher risk for in-hospital mortality is essential to guide management and improve prognosis.

METHODS

A retrospective analysis was conducted of a cohort of patients followed up from 1978 to 2015, classified according to the modified Duke criteria. Clinical parameters, echocardiographic data, and blood cultures were assessed. Techniques of machine learning, such as the classification tree, were used to explain the association between clinical characteristics and in-hospital mortality. Additionally, the log-linear model and graphical random forests (GRaFo) representation were used to assess the degree of dependence among in-hospital outcomes of IE.

RESULTS

This study analyzed 653 patients: 449 (69.0%) with definite IE; 204 (31.0%) with possible IE; mean age, 41.3 ± 19.2 years; 420 (64%) men. Mode of IE acquisition: community-acquired (67.6%), nosocomial (17.0%), undetermined (15.4%). Complications occurred in 547 patients (83.7%), the most frequent being heart failure (47.0%), neurologic complications (30.7%), and dialysis-dependent renal failure (6.5%). In-hospital mortality was 36.0%. The classification tree analysis identified subgroups with higher in-hospital mortality: patients with community-acquired IE and peripheral stigmata on admission; and patients with nosocomial IE. The log-linear model showed that surgical treatment was related to higher in-hospital mortality in patients with neurologic complications.

CONCLUSIONS

The use of a machine-learning model allowed identification of subgroups of patients at higher risk for in-hospital mortality. Peripheral stigmata, nosocomial IE, absence of vegetation, and surgery in the presence of neurologic complications are predictors of fatal outcomes in machine learning-based analysis.

Reassessment of vegetation size as a sole indication for surgery in left-sided infective endocarditis

BACKGROUND

Guidelines recommend surgery in left-sided infective endocarditis (LSIE) associated with large vegetations. Given that most patients who undergo surgery also have other indications (heart failure and/or uncontrolled infection), it is not settled whether surgery should be routinely recommended in patients with large vegetations but no other predictors of poor outcome.

METHODS

A total of 726 patients with definitive LSIE were included in our analysis. Mean age was 64.9 years, 61% were male. Multivariate analysis of all patients was performed to determine if vegetation size is related to death in LSIE. Then, patients were divided in two groups according to vegetation size: Group A (>10 mm, n=420) and group B (≤10 mm, n=306). Univariate and multivariate analyses of group A patients were carried out to identify the variables related to death in this group. Impact of surgery on mortality of group A patients without heart failure or uncontrolled local infection (n=139) was assessed.

RESULTS

Age, Staphylococcus aureus, perivalvular complications, heart failure, kidney failure and septic shock, but not vegetation size, were associated with death. Patients with large vegetations showed increased mortality (31.7% in group A vs 24.8% in group B, p=0.045). Group A had more valve rupture and valve regurgitation than group B, but heart failure (55% vs 53%, p=0.678), stroke (22% vs 17.0%, p=0.091), systemic embolism (39% vs 32%, p=0.074), perivalvular complication (28% vs 28%, p=0.865) or septic shock (15% vs 13%, p=0.288) were similar in both groups. In patients from group A without heart failure or uncontrolled infection mortality was similar with and without surgery (n=139; n=70 with surgery, n=69 without surgery; mortality 18.6% vs 11.6% respectively, p=0.251).

CONCLUSIONS

large vegetations identify patients with poor outcome in LSIE. However, surgery is not associated with a better prognosis in patients with large vegetations if they do not present with another predictor of poor outcome such as heart failure or uncontrolled infection. These findings challenge whether vegetation size alone should be an indication for surgery in LSIE.

Minimally invasive surgery versus sternotomy in native mitral valve endocarditis: a matched comparison

OBJECTIVES

The present study compared the clinical outcomes between minimally invasive surgery (MIS) and median sternotomy (MS) in patients with native mitral valve infective endocarditis.

METHODS

From 2009 to 2019, a total of 154 patients with acute (n = 131, 85%) or subacute (n = 23, 15%) native mitral valve infective endocarditis were included in the study. One-to-one nearest neighbour propensity score matching considering endocarditis severity using the dedicated De Feo score and 19 other clinically relevant baseline variables resulted in a population of 39 matched pairs. The matched cohort was investigated regarding operative and postoperative outcomes.

RESULTS

Both groups showed similar results regarding cardiopulmonary bypass time [MIS: 96 min (77-138), MS: 99 min (88-127); P = 0.780] and aortic cross-clamp time [MIS: 64 min (54-90), MS: 65 min (59-83); P = 0.563], whereas overall operative time was shorter through minimally invasive access [MIS: 138 min (112-196), MS: 187 min (175-230); P = 0.005]. Although the rate of revision for bleeding was similar in both groups [MIS: 12.8% (n = 5), MS: 10.3% (n = 4); P = 1.000], MIS was associated with fewer red blood cell unit transfusions [MIS: 1 unit (0-4), MS: 4 units (2-10); P = 0.001] and fewer fresh frozen plasma unit transfusions [MIS: 0 units (0-0), MS: 1 unit (0-5); P = 0.002]. MIS was associated with a shorter ventilation time [MIS: 708 min (429-1236), MS: 1440 min (659-4411); P = 0.024] and a lower rate of reintubation after extubation [MIS: 5.1% (n = 2), MS: 25.6% (n = 10); P = 0.021].

CONCLUSIONS

In patients suffering from native mitral valve infective endocarditis, MIS provides significant clinical benefits over sternotomy in selected patients.

SUBJECT COLLECTION

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Comparison of outcome between blood culture positive and negative infective endocarditis patients undergoing cardiac surgery

Background

Up to 30% or even more of all infective endocarditis (IE) cases are recognized as blood culture negative, meaning that the causative agent is left unidentified. The prompt diagnosis together with the identification of causative microorganism and targeted antibiotic treatment can significantly impact the prognosis of the disease and further patient’s health status. In some studies, blood culture negative endocarditis has been shown to be associated with delayed diagnosis, worse outcome and course of the disease, and a greater number of intra and postoperative complications.

Methods

We retrospectively analysed the medical records of all patients who underwent cardiac surgery for endocarditis between years 2016 and 2019. The aim of this study was to analyse short and long-term mortality and differences of laboratory, clinical and echocardiography parameters in patients with blood culture positive endocarditis (BCPE) and blood culture negative endocarditis (BCNE) and its possible impact on the clinical outcome.

Results

In our study population were 114 (55.1%) blood culture positive and 93 (44.9%) blood culture negative cases of infectious endocarditis. The most common pathogens in the blood culture positive IE group were S.aureus in 36 cases (31.6%), Streptococcus spp. in 27 (23.7%), E.faecalis in 24 (21.1%), and other microorganisms in 27 (23.7%). Embolic events were seen in 60 patients (28.9%). In univariate analyses, detection of microorganism, elevated levels of procalcitonin were found to be significantly associated with intrahospital death, however it did not reach statistical significance in multivariate analyses. Among microorganisms, S.aureus was significantly associated with intrahospital death in both univariate and multivariate analyses.

Conclusions

There are no statistically significant differences between groups of BCPE and BCNE in terms of intrahospital mortality, hospital and ICU stay or 3-year mortality.

There were higher levels of procalcitonin in BCPE group, however procalcitonin failed to show independent association with mortality in multivariate analysis.

The most common microorganism in the BCPE group was S.aureus. It was associated with independently higher intrahospital mortality when compared to other causative microorganisms.

Long-term antibiotic therapy in patients with surgery-indicated not undergoing surgery infective endocarditis

BACKGROUND

To date, there is little information regarding management of patients with infective endocarditis (IE) that did not undergo an indicated surgery. Therefore, we aimed to evaluate prognosis of these patients treated with a long-term antibiotic treatment strategy, including oral long term suppressive antibiotic treatment in five referral centres with a multidisciplinary endocarditis team.

METHODS

This retrospective, multicenter study retrieved individual patient-level data from five referral centres in Spain. Among a total of 1797, 32 consecutive patients with IE were examined (median age 72 years; 78% males) who had not undergone an indicated surgery, but received long-term antibiotic treatment (LTAT) and were followed by a multidisciplinary endocarditis team, between 2011 and 2019. Primary outcomes were infection relapse and mortality during follow-up.

RESULTS

Among 32 patients, 21 had IE associated with prostheses. Of the latter, 8 had an ascending aorta prosthetic graft. In 24 patients, a switch to long-term oral suppressive antibiotic treatment (LOSAT) was considered. The median duration of LOSAT was 277 days. Four patients experienced a relapse during follow-up. One patient died within 60 days, and 12 patients died between 60 days and 3 years. However, only 4 deaths were related to IE.

CONCLUSIONS

The present study results suggest that a LTAT strategy, including LOSAT, might be considered for patients with IE that cannot undergo an indicated surgery. After hospitalization, they should be followed by a multidisciplinary endocarditis team.

A narrative review of the interpretation of guidelines for the treatment of infective endocarditis

The recommendations of the current guidelines and the position papers of professional societies from the European Society of Cardiology/European Society of Cardiothoracic Surgeons (ESC), the American College of Cardiology/American Heart Association/Society of Thoracic Surgeon (ACC/AHA/STS) and American Association of Thoracic Surgeon (AATS) regarding management of patients with valvular heart endocarditis were updated over the past decade. However, some of the recommendations appear to contradict one another. Given the changing paradigms on how the disease manifests, our aim was to review the respective guidelines and highlight these differences whilst drawing attention to the subsequent studies from which they were derived. In particular, concerns regarding antibiotic prophylaxis and therapy, imaging modality for diagnosis and follow-up, cerebrovascular sequalae and timing of surgery are appraised in detail. We also identified the novel techniques used such as transcatheter therapies and advances in imaging modalities used for diagnosis and treatment of this condition. The lack of randomised control trials (RCTs) does raise several issues regarding applicability of findings in day-to-day practice. Therefore, the focus of upcoming studies should be on clearly defined multicenter RCTs to provide more robust evidence for the management and treatment of infective endocarditis as future guidelines will be based on the outcomes of these trials.

Short- and long-term mortality in patients with left-sided infective endocarditis not undergoing surgery despite indication

INTRODUCTION AND OBJECTIVES

In infective endocarditis (IE), decisions on surgical interventions are challenging and a high percentage of patients with surgical indication do not undergo these procedures. This study aimed to evaluate the short- and long-term prognosis of patients with surgical indication, comparing those who underwent surgery with those who did not.

METHODS

We included 271 patients with left-sided IE treated at our institution from 2003 to 2018 and with an indication for surgery. There were 83 (31%) surgery-indicated not undergoing surgery patients with left-sided infective endocarditis (SINUS-LSIE). The primary outcome was all-cause death by day 60 and the secondary outcome was all-cause death from day 61 to 3 years of follow-up. Multivariable Cox regression and propensity score matching were used for the analysis.

RESULTS

At the 60-day follow-up, 40 (21.3%) surgically-treated patients and 53 (63.9%) SINUS-LSIE patients died (P <.001). Risk of 60-day mortality was higher in SINUS-LSIE patients (HR, 3.59; 95%CI, 2.16-5.96; P <.001). Other independent predictors of the primary endpoint were unknown etiology, heart failure, atrioventricular block, and shock. From day 61 to the 3-year follow-up, there were no significant differences in the risk of death between surgically-treated and SINUS-LSIE patients (HR, 1.89; 95%CI, 0.68-5.19; P=.220). Results were consistent after propensity score matching. Independent variables associated with the secondary endpoint were previous IE, diabetes mellitus, and Charlson index.

CONCLUSIONS

Two-thirds of SINUS-LSIE patients died within 60 days. Among survivors, the long-term mortality depends more on host conditions than on the treatment received during admission.

[Infective endocarditis in Morocco through the experience of a hospital department]

Infective endocarditis is a grave disease because of a high level of morbidity and mortality. We conducted a retrospective analysis of 100 patients hospitalized for infective endocarditis from January 2009 until December 2015. The mean age was 41 years with a male predominance. Infective endocarditis occurs on a native valve (77 patients), prosthetic valves (12 patients), Pacemaker (7 patients) and congenital heart disease (4 patients). The diagnostic delay was 77 days on average. The fever was present in 85 patients. Blood cultures were negative in 54 patients. Echocardiography allowed visualizing the vegetations in 95 patients. In patients with prosthetics valves, a paraprosthetic regurgitation was diagnosed in 54 % of these patients and vegetation in 18 %. The main complications are heart failure (42), neurological (19), spleen (10) and renal (23) complications. The evolution under medical treatment was marked by the clinical-laboratory improvement in 57 patients, the lack of improvement with persistent fever in 21 patients. The mortality rate of our series is 23 %. Only seven patients underwent urgent surgery for hemodynamic and infectious indications. At the end of this work, it is emphasized that the epidemiological profile of infective endocarditis does not follow the changes of Wold. Its management is difficult in our context (significant diagnostic delay, often negative blood cultures, high level of morbidity, lack of recourse to early surgery). The improvement of this disease consistes of the prevention of acute articular rhumatism and the establishment of an heart team endocarditis to adapt international recommendations to our context.

Effect of cerebral embolus size on the timing of cardiac surgery for infective endocarditis in patients with neurological complications

The optimal timing of cardiac surgery remains unclear for patients with neurological complications of infective endocarditis (IE). However, neuroimaging findings may allow more refined clinical decision-making. We analyzed clinical and advanced neuroimaging data for 135 patients with IE who had preoperatively diagnosed ischemic cerebral complications (86 patients) or hemorrhagic complications (49 patients), between January 1997 and May 2013. The effect of early surgery (within 3 and 7 days of ischemic and hemorrhagic complications respectively) on in-hospital mortality and 1-year adverse outcomes (mortality, relapse, or new embolic events) was estimated. Small cerebral emboli (≤2 cm) led to early surgery (cases with ischemic complications: 57% vs 26%, p = 0.04; cases with hemorrhagic complications: 56% vs 13%, p = 0.02). Early surgery was not significantly associated with increased rates of in-hospital mortality and 1-year adverse outcomes among patients with ischemic complications (14% vs 9%, odds ratio [OR] 1.67, 95% confidence interval [CI] 0.44-6.38, p = 0.52; 17% vs 14%, OR 1.27, 95% CI 0.39-4.14, p = 0.7 respectively). Only 1 patient (4%) with hemorrhagic complications experienced in-hospital mortality in the early surgery group, and early surgery was not significantly associated with 1-year adverse outcomes (21% vs 12%, OR 1.93, 95% CI 0.41-9.16, p = 0.46). The risks of in-hospital mortality and 1-year adverse outcome were not increased, even if cardiac surgery had been carried out earlier than previously described. Our findings suggest that early surgery, when indicated, may be performed for patients with IE and neurological complications, especially if the cerebral embolus has a diameter of ≤2 cm.

Challenges in Infective Endocarditis

Infective endocarditis is defined by a focus of infection within the heart and is a feared disease across the field of cardiology. It is frequently acquired in the health care setting, and more than one-half of cases now occur in patients without known heart disease. Despite optimal care, mortality approaches 30% at 1 year. The challenges posed by infective endocarditis are significant. It is heterogeneous in etiology, clinical manifestations, and course. Staphylococcus aureus, which has become the predominant causative organism in the developed world, leads to an aggressive form of the disease, often in vulnerable or elderly patient populations. There is a lack of research infrastructure and funding, with few randomized controlled trials to guide practice. Longstanding controversies such as the timing of surgery or the role of antibiotic prophylaxis have not been resolved. The present article reviews the challenges posed by infective endocarditis and outlines current and future strategies to limit its impact.