Neurological complications and clinical outcomes of infective endocarditis

A Rare Case of Prosthetic Mitral Valve Endocarditis With Atrial and Ventricular Lead Infections

This is the case of a patient in their 30s who is known to have a prosthetic mitral valve replacement and a cardiac pacemaker that presented to the hyper-acute stroke unit with collapse, left-sided dense weakness, back pain, dyspnea, and hypoxia. Investigations showed bilateral areas of intracerebral haemorrhage. Transthoracic echocardiogram (TTE) showed prosthetic mitral valve, atrial and ventricular lead vegetations with severe valvular incompetence due to the valve being markedly thickened with mobile oscillating masses seen on atrial and ventricular sides. The patient was not a candidate for surgical management given a history of continuous intravenous drug use (IVDU) as well as significant risks posed by haemorrhagic stroke and poor previous post-operative compliance. While the patient initially showed improvement with medical management, including appropriate antibiotics, persistent staphylococcus aureus bacteremia remained. Despite ongoing treatment efforts, the patient experienced clinical deterioration and succumbed to their illness from multi-organ failure. This case highlights the challenges in managing infective endocarditis involving prosthetic valves and cardiac devices, particularly in the setting of contraindications to surgical intervention and significant comorbidities. It highlights the need for a multidisciplinary approach to balance the risks of surgical versus medical management in complex cases, as well as the importance of early recognition and tailored therapeutic strategies.

The Impact of Neurological Complications in Endocarditis: A Systematic Review and Meta-Analysis

Background: Infective endocarditis (IE) is associated with significant neurological complications (NCs). The impact of neurological sequelae due to IE, however, is not well characterized. Thus, the aim of this systematic review and meta-analysis is to determine whether patients who experienced NCs from IE had worse outcomes compared to those without neurological complications. Methods: We conducted a systematic and comprehensive literature search of MEDLINE, Cochrane Library, Google Scholar, and BioMed Central (PROSPERO registration ID: CRD42024518651). Data on the primary outcome of all-cause mortality and the secondary outcome of surgical timing were extracted from 25 observational studies on patients with confirmed IE, both with and without NC. Results: In the pooled total of patients with IE, NCs were present in 23.7% (60.8% ischaemic stroke and 16.4% haemorrhagic stroke). All-cause mortality was significantly higher in patients with IE and NCs (OR 1.78, CI 1.47-2.17, p < 0.0001) compared to those without, particularly in those with major neurological events (OR 2.18, CI 1.53-3.10, p < 0.0001). Conversely, minor or asymptomatic strokes showed no significant correlation with mortality (OR 1.10, CI 0.82-1.47, p = 0.543). There was no significant difference in the timing of surgical intervention (standardized mean difference -0.53, CI -1.67 to 0.61, p = 0.359) between the two patient groups. Conclusions: Major NCs due to infective endocarditis were associated with a significantly increased all-cause mortality. This underscores the critical importance of early recognition and management strategies tailored to the severity of neurological events.

Prevalence and prognostic impact of stroke in a national cohort of infective endocarditis

BACKGROUND

Stroke is a common complication of infective endocarditis (IE). Our aim was to describe the prevalence and prognostic impact of stroke in a national cohort of IE.

METHODS

Consecutive inclusion at 46 Spanish hospitals between 2008 and 2021.

RESULTS

Out of 5667 IE cases, 1125 had acute stroke (19.8%): 818 ischemic strokes (811 cardioembolic strokes (193 with hemorrhagic transformation), 4 transient ischemic attacks, 3 lacunar infarctions), 127 intracranial hemorrhages, and 27 other neurological complications (cerebral abscesses, encephalitis, and meningitis). Compared to patients without stroke, those with stroke had a similar mean age (69 years) but were more frequently female (68.2% vs 63.7%, p = 0.04) and had a higher incidence of intracardiac complications (35% vs 30%, p = 0.01), surgical indication (69.9% vs 65.9%, p = 0.001), in-hospital mortality (40.9% vs 22.0%, p < 0.001), and 1-year mortality (46.2% vs 27.9%, p < 0.001). The following variables were independently associated with stroke: mitral location (odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.34-1.8, p < 0.001), vascular phenomenon (OR = 2.9, 95% CI = 2.4-3.6, p = 0.0001), acute renal failure (OR = 1.2, 95% CI = 1.0-1.4, p = 0.021), septic shock (OR = 1.3, 95% CI = 1.1-1.6, p = 0.007), sepsis (OR = 1.3, 95% CI = 1.1-1.6, p = 0.005), surgery indicated but not performed (OR = 1.4, 95% CI = 1.2-1.7, p < 0.001), community-acquired IE (OR = 1.2, 95% CI = 1-1.4, p = 0.017), and peripheral embolization (OR = 1.6, 95% CI = 1.4-1.9, p < 0.001). Stroke was an independent predictor of in-hospital (OR = 2.1, 95% CI = 1.78-2.51, p < 0.001) and 1-year mortality (hazard ratio = 1.9, 95% CI = 1.6-2.5).

CONCLUSION

One-fifth of patients with IE have concomitant stroke. Stroke is associated with mortality.

From flank pain to splenic abscess: a complex case of infective endocarditis with literature review

BACKGROUND

Infective endocarditis (IE) is a severe condition characterized by inflammation of the heart endocardium and valves, commonly caused by Gram-positive bacteria. Complications such as embolic phenomena and organ abscesses can arise, necessitating timely diagnosis and intervention.

CASE PRESENTATION

We report the case of a 20-year-old female with a history of cerebral and splenic infarctions due to IE. The patient presented with left-sided flank pain, urinary burning, and fever. Examination revealed mitral and aortic valve involvement, splenomegaly, and neurological deficits. Despite initial antibiotic therapy, the patient developed a splenic abscess and drug-induced neutropenia. She required aortic valve replacement and was successfully managed with a multidisciplinary approach.

CONCLUSION

Multidisciplinary management, including timely surgical intervention and advanced imaging, is essential for favorable outcomes in IE patients. This case underscores the importance of early detection and tailored treatment strategies in managing severe complications associated with IE.

[Infective endocarditis : In-hospital mortality predictive factors]

INTRODUCTION

Infective endocarditis (IE) remains a serious disease with significant morbidity and mortality despite therapeutic advancements. The aim of our study was to determine the predictive factors of in-hospital mortality.

PATIENTS AND METHODS

A prospective comparative study over a period of 54 months was conducted, including all patients admitted for definite infective endocarditis, diagnosed according to the modified Duke criteria published in 2015 by the European Society of Cardiology.

RESULTS

Thirty-four patients were included. Drug addiction was the main risk factor for infective endocarditis (56%). Tricuspid valve involvement was predominant (50%). Staphylococcus aureus was the most commonly isolated pathogen (65%). In-hospital mortality rate was 47%. In multivariate analysis, predictive factors for mortality were acute heart failure (OR=7.4; p=0.026; 95% CI [1.2-44]) and cerebral embolic localization (OR=11.1; p=0.024; 95% CI [13-90]).

CONCLUSIONS

Cardiac and cerebral complications influence the prognosis of IE. Thus, close collaboration among multidisciplinary teams is necessary for improved diagnostic and therapeutic management.

Cat Scratch Endocarditis

We reported a case of blood culture-negative infective endocarditis on a native valve, where the clinical presentation was exclusively related to extensive cerebral ischemia secondary to multiple systemic septic cardioembolic events. The cause was ascribed to subacute Bartonella henselae infection, presumably transmitted by cat scratch, documented by positive serologic findings.

A Bayesian network-based approach for identifying risk factors and predicting ischemic stroke in infective endocarditis patients

Objective

This study aimed to seek the risk factors and develop a predictive model for ischemic stroke (IS) in patients with infective endocarditis (IE) utilizing a Bayesian network (BN) approach.

Methods

Data were obtained from the electronic medical records of all adult patients at three hospitals between 1 January 2018, and 31 December 2022. Two predictive models, logistic regression and BN, were used. Patients were randomly assigned to the training and test sets in a 7:3 ratio. We established a BN model with the training dataset and validated it with the testing dataset. The Bayesian network model was built by using the Tabu search algorithm. The areas under the receiver operating characteristic curve (AUCs), calibration curve, and decision curve were used to evaluate the prediction performance between the BN and logistic models.

Results

A total of 542 patients [mean (SD) age, 49.6 (15.3) years; 137 (25.3%) female] were enrolled, including 151 (27.9%) with IS and 391 (72.1%) without IS. Hyperlipidemia, hypertension, age, vegetation size (>10 mm), S. aureus infection, and early prosthetic valve IE were closely correlated with IS. The BN models outperformed the logistic regression in training and testing sets, with accuracies of 76.06% and 74.1%, AUC of 0.744 and 0.703, sensitivities of 25.93% and 20.93%, and specificities of 96.27% and 90.24%, respectively.

Conclusion

The BN model is more efficient than the logistic regression model. Therefore, BN models may be suitable for the early diagnosis and prevention of IS in IE patients.

Posterior Mitral Leaflet Prolapse and Subsequent Mitral Valve Endocarditis Complicated With Anterior Leaflet Perforation

A 68-year-old male presented with a two-week history of fever, and further investigations revealed mitral valve endocarditis caused by Staphylococcus epidermidis, with associated severe mitral regurgitation (MR). The patient was referred for mitral valve surgery but developed new neurological symptoms two days before the operation, which were diagnosed as symptomatic epilepsy. During surgery, kissing lesions were found on the posterior mitral leaflet (PML), which were not detected on preoperative transesophageal echocardiography (TEE). Mitral valve repair was completed using autologous pericardium. The current case highlights the importance of careful examination of leaflets during surgery and not relying solely on preoperative imaging to detect all lesions. It is essential to promptly diagnose and treat infective endocarditis to prevent further complications and ensure successful outcomes.

Risk factors for neurological complications in left-sided infective endocarditis

BACKGROUND AND PURPOSE

Neurological complications following infective endocarditis (IE) directly contribute to long-term morbidity. We examined the risk factors for different neurological complications of left-sided IE.

METHODS

Using a database of consecutive adults admitted to a health system with left-sided IE from 2015 to 2019, the frequency of cerebral infarcts, intraparenchymal hemorrhage, cerebral microbleeds (CMB), mycotic aneurysm, and encephalopathy was determined. Variables with significant differences comparing each neurological complication (p < 0.1) were entered into regression models along with age to determine predictors.

RESULTS

211 patients with mean age 54 (±18) years, and 69 (33%) females were included. Infarcts were found in 118 (56%) patients, intraparenchymal hemorrhage was found in 17 (8%) patients, CMB were found in 58 (27%) patients, mycotic aneurysms were found in 22 (10%) patients, and encephalopathy occurred in 16 (8%) patients. In multivariable models, vegetation size ≥15 mm was associated with a higher risk of infarcts (aOR 2.26, 95% CI (1.12-4.57)), and the presence of a mycotic aneurysm was a risk factor for intraparenchymal hemorrhage (aOR 18.79, 95% CI (3.97-88.97)). Prosthetic valves (aOR 2.89, 95% CI (1.11-7.54)) and Staphylococcus aureus infection (aOR 3.50, 95% CI (1.08-11.36)) were associated with CMB. No risk factors emerged as predictors of encephalopathy.

CONCLUSIONS

Large vegetation size is associated with stroke in patients with IE. Mycotic aneurysms are found at a higher frequency in young patients and are the primary cause of intraparenchymal hemorrhage. CMB may be related to prosthetic valves and Staphylococcus aureus infection.