Right-Sided Infective Endocarditis and Pulmonary Infiltrates: An Update

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.

A rare complication of blood culture-negative infective endocarditis on tricuspid valve: case report

Background

Endocarditis is an infectious disease, with an incidence of ∼15 cases per 100 000 people, affecting the tricuspid valve in 10% of cases. Infective endocarditis with negative blood cultures (BCNIE) accounts for more than 20% of cases of infective endocarditis. Perivalvular extension of the infection represents the most detrimental complications of BCNIE.

Case summary

A 25-year-old South Asian male was admitted due to fever for 15 days and new onset chest pain. The blood tests showed an increase in inflammatory indices. A chest X-ray showed enlargement of the cardiac shadow. On cardiac examination, a holosystolic murmur at the left sternal edge border was heard. The transthoracic echocardiogram showed a filamentous formation on the tricuspid valve and communication between the aorta and right atrium with left-right shunt. A transoesophageal echocardiogram (TEE) was performed to confirm the diagnosis of IE. Three sets of blood cultures were performed, with negative results, empirical therapy was managed and a decision for TEE-guided cardiac surgery was made.

Discussion

Fistula is a rare complication of IE representing the most insidious consequence of uncontrolled infection like BCNIE, a condition that has restricted the therapeutic possibilities to empirical therapy only and to early surgery. The TEE was instrumental in diagnosing right-sided infective endocarditis and allowing us to focus on the perivalvular spread of the infection in our case.

Prosthetic Joint Infection Complicated by Staphylococcus aureus Bacteremia and Tricuspid Valve Infective Endocarditis: A Novel Case Report

Prosthetic joint infection (PJI) is defined as an infection involving the prosthesis and surrounding soft tissue and bone that is a difficult complication to treat and is a common cause of revision total joint arthroplasty (TJA). Bacteremia, sepsis, and infective endocarditis (IE) are rare complications in patients who have undergone TJA. We report a rare case where a patient presented with purulent discharge from the left knee joint post-TJA concerning PJI and was found to have methicillin-sensitive Staphylococcus aureus bacteremia, tricuspid valve endocarditis, and septic pulmonary emboli. The patient underwent irrigation, debridement, and a spacer device placement in the affected knee joint for PJI and was medically treated for IE with six weeks of antibiotic therapy. The patient successfully recovered and was discharged to a rehabilitation facility. We conclude that PJI and IE secondary to TJA are very rare, but given the high morbidity and mortality, if diagnosis and treatment are delayed, physicians should always remain vigilant for these complications in the appropriate clinical context.

Left-sided infective endocarditis presenting with pulmonary involvement and liver abscess: A case report

Key Clinical Message

Infective endocarditis is an important differential diagnosis in patients with persistent fever and chills not responding to antibiotics and involvement of multiple organs. It can present without any specific signs such as valvular murmurs and no growth on blood cultures. Therefore, considering an echocardiography can be crucial and helpful in establishing the diagnosis.

Abstract

Infective endocarditis (IE), a rare disease with high mortality, arises from microbial infection affecting the heart valves and endocardium. It exhibits diverse symptoms and can involve various organs, including the brain, lungs, spleen, and liver. Diagnosis is often intricate due to its polymorphic nature, and negative blood cultures can add complexity to the diagnostic process. In this report, we present an unusual case of IE in a 53-year-old male farmer with multi-organ involvement, including liver abscesses and pulmonary infiltration with cavities. Echocardiography showed a nodular mass attached to his bicuspid aortic valve, thus, playing a crucial role in confirming the diagnosis. This atypical manifestation highlights the necessity for increased clinical vigilance and further research to improve diagnostic approaches for uncommon IE cases.

Pylephlebitis and Right-Sided Endocarditis: A Rare Complication of an Intra-abdominal Infection

Right-sided infective endocarditis is less common than left-sided endocarditis and can be a difficult clinical diagnosis. The presence of intracardiac devices is a major risk factor. The presentation is less clear than left-sided forms because of the presence of respiratory symptoms and the absence of systemic embolization. Pylephlebitis, or septic thrombosis of the portal vein, is a serious infectious condition that often delays diagnosis. It is a complication of intraabdominal or pelvic infections. Streptococcus gallolyticus (S. gallolyticus) can cause infective endocarditis and is associated with colon neoplasia and hepatobiliary disease. In this case report, we describe the case of a 76-year-old male with a history of rectal adenocarcinoma who presented with different episodes of fever of unknown origin (FUO), one of which occurred after pacemaker implantation. Ultimately, he was diagnosed with S. gallolyticus-mediated tricuspid valve endocarditis with underlying pylephlebitis. Investigations did not show evidence of pacemaker lead endocarditis.

A Large Tricuspid Subvalvular Apparatus Infective Endocarditis Undetected by Transthoracic Echocardiography

A 39-year-old male with a history of intravenous drug use (IVDU) and no significant cardiovascular disease was admitted to the ICU for management of septic shock and acute hypoxic respiratory failure secondary to septic pulmonary emboli. Due to a high clinical suspicion for right-sided infective endocarditis (IE), he received a transthoracic echocardiogram (TTE), which did not reveal any vegetations. However, a transesophageal echocardiogram (TEE) was subsequently performed; this showed a large 2.4 cm vegetation in the septal aspect of the tricuspid valve (TV) subvalvular apparatus. He urgently underwent surgical removal of the vegetation and repair of the TV. Postoperatively, he clinically recovered with appropriate antibiotic therapy. TEE is the ideal imaging modality in evaluation for IE, but a minimally invasive TTE is often performed first. This case highlights a highly unusual anatomic location of IE, which harbored a large vegetation undetected by TTE. In patients without cardiac devices or non-native valves, an urgent TEE remains diagnostically essential if there is a high clinical suspicion for right-sided IE, even if a TTE shows no evidence of IE.

S, Shahi M, Khan A, Rijal Y, Gurung B, Kurmi RN. Infective endocarditis of tricuspid valve following septic abortion: a case report

Introduction

Right-sided infective endocarditis (IE) in non-intravenous drug users is a rare finding. IE of the tricuspid valve is considered an important but uncommon complication in patients with a recent history of obstetric and gynecological procedures.

Case presentation

We report a case of a 28-year-old female with IE of the tricuspid valve with a prior history of dilatation and curettage. The echocardiography revealed two mobile vegetation in the septal leaflet of the tricuspid valve with severe eccentric tricuspid regurgitation. Blood culture was positive for Staphylococcus aureus. The patient was started on intravenous (i.v.) antibiotics with supportive treatments and improved over the days.

Clinical discussion

Infection can get access to the venous system via pelvic veins after the septic obstetric and gynecological procedure and subsequently to the right side of the heart. Different studies have highlighted the role of prophylactic antibiotics in significantly reducing post-abortal infections. In our patient, the disease was diagnosed on the basis of clinical, echocardiographic, and blood culture findings, and the patient responded well to i.v. antibiotics and supportive care under close monitoring in the coronary care unit.

Conclusion

It is important for healthcare providers to be aware of the risk factors and symptoms associated with right-sided IE for early diagnosis and treatment. Appropriate antibiotic prophylaxis and adherence to sterile techniques can help to prevent IE.

Streptococcus oralis pulmonic valve endocarditis: a case report and review of the literature

BACKGROUND

Several factors increase the risk of right-sided endocarditis. The tricuspid valve is usually involved in right-sided endocarditis cases. Infective endocarditis of the pulmonic valve is rare, and few cases of pulmonic valve endocarditis were reported previously.

CASE PRESENTATION

Here we describe a case of a 81-year-old Middle Eastern male patient, admitted to our hospital three times in a period of 2 months for fever and cough. He had Streptococcus oralis bacteremia with vegetation that was on the pulmonic valve. We diagnosed him with pulmonic valve endocarditis, and he was treated successfully with intravenous antibiotics.

CONCLUSION

It is important to keep high suspicion for isolated pulmonic valve endocarditis in patients with respiratory symptoms. Adequate dental care is important in patients with risk factors for infective endocarditis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Outcomes of Patients Hospitalized With Cardiovascular Implantable Electronic Device-Related Infective Endocarditis, Prosthetic Valve Endocarditis, and Native Valve Endocarditis: A Nationwide Study, 2003 to 2017

Background

Most published reports describing outcomes of patients with cardiovascular implantable electronic device–related infective endocarditis (CIED‐IE) are single‐center studies with small patient sample sizes. The goal of this study was to utilize population‐based data to assess trends in CIED‐IE hospitalization and to compare outcomes between patients hospitalized with CIED‐IE, prosthetic valve endocarditis (PVE), and native valve endocarditis (NVE).

Methods and Results

A query of the National (Nationwide) Inpatient Sample (NIS) database between 2003 and 2017 identified 646 325 patients hospitalized with infective endocarditis in the United States of whom 585 974 (90%) had NVE, 27 257 (4.2%) had CIED‐IE, and 26 111 (4%) had PVE.

There was a 509% increase in CIED‐IE hospitalizations in the United States from 2003 to 2017 (P trend<0.001). In‐hospital mortality and length of stay associated with CIED‐IE decreased during the study period from 15% and 20 days in 2003 to 9.7% and 19 days in 2017 (P trend=0.032 and 0.018, respectively). The in‐hospital mortality rate was lower in patients hospitalized with CIED‐IE (9.2%) than in patients with PVE (12%) and NVE (12%). Length of stay was longest in the CIED‐IE group (17 compared with 14 days for both NVE and PVE). Hospital costs were highest for the CIED‐IE group ($56 000 compared with $37 000 in NVE and $45 000 in PVE).

Conclusions

Despite the fact that the number of comorbidities per patient with CIED‐IE increased during the study period, mortality rate and hospital length of stay decreased. The mortality rate was significantly lower for patients with CIED‐IE than for patients with NVE and PVE. Patients with CIED‐IE had the longest lengths of stay and highest hospital costs.

Cardiac Imaging for Diagnosis and Management of Infective Endocarditis

Imaging is central to the care of patients with infective endocarditis. While transthoracic and transesophageal echocardiography are the principle imaging techniques, additional modalities including positron emission tomography and cardiac computed tomography, and to a lesser extent intracardiac echocardiography, play an increasing role. This review discusses the role of cardiac imaging in establishing the diagnosis of endocarditis, in predicting its embolic risk and in making decisions regarding the need for and timing of surgery.

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

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

A Novel Technique Debulking Vegetations in Tricuspid Endocarditis and Venacava Utilizing AngioVac Aspiration System

The AngioVac system (AngioDynamics Inc., Latham, NY) is used for the removal of commonly encountered intravascular material, such as thrombus or vegetations in the right atrium, right ventricle, superior vena cava, and inferior vena cava. Patients with high surgical risk having tricuspid endocarditis and superior vena cava thrombus can be treated with the AngioVac system, hence mitigating the risks for this patient population. We present a case series with the utilization of the AngioVac device to reduce the vegetation size and decrease the risk of emboli with effective antibiotic penetration. Transesophageal echocardiography shows a reduction in the size of the vegetations in all three cases with no postoperative complications. This case series demonstrates a novel technique debulking vegetations in tricuspid endocarditis and vena cava.

Anesthesia Considerations in Infective Endocarditis

The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.

Drug use-related right-sided infective endocarditis complicated by empyema and bronchopleural fistula

Right-sided infective endocarditis is frequently accompanied by septic pulmonary emboli, which may result in a spectrum of respiratory complications. We present the case of a 25-year-old woman diagnosed with infective endocarditis secondary to intravenous drug use. During a long and arduous hospital course, the patient developed empyema with bronchopleural fistula, representing severe but uncommon sequelae that may arise from this disease process. She was treated with several weeks of antibiotics as well as surgical thorascopic decortication and parietal pleurectomy.

Gemella endocarditis

We herein present the case presenting to our facility complaining of a fever of two months duration, who underwent dental procedure. Patient was diagnosed with infective endocarditis secondary to an uncommon bacteria: Gemella haemolysans. Patient was found to have concomitant severe mitral valve regurgitation. Our patient did not have any comorbidity or risk factor beside his dental procedure. Our patient received intravenous antibiotic therapy for six weeks and was scheduled for mitral valve replacement.

Double Valve Infective Endocarditis Complicated by Systemic Arterial Embolization

A 26-year-old male with a past medical history of intravenous opioid abuse was admitted with the diagnosis of double valve infective endocarditis and methicillin-resistant Staphylococcus aureus bacteremia. Imaging, excluding the head, was indicative of systemic arterial embolization, as abscesses had developed in the retroperitoneum and prostate. There was evidence of splenic infarct, and the presence of extensive pulmonary infiltrates indicative of showering septic foci from the heart. Antibiotic therapy was started and a transesophageal echocardiogram demonstrated mitral and tricuspid valve vegetations with a preserved ejection fraction. Fortunately, the valvular repair was successful and artificial valves were not needed. The patient had an uncomplicated postoperative course in the intensive care unit and was transferred back to the ward in stable condition. He remained on the ward for six weeks due to his unfunded status until his antibiotic course and physical rehabilitation were completed.

Tricuspid valve endocarditis: Cardiovascular imaging evaluation and management

Right-sided infective endocarditis is an increasingly recognized disease entity, with tricuspid valve being most frequently involved. Risk factors for tricuspid valve endocarditis (TVIE) include intravenous drug use, cardiac implantable electronic devices and indwelling catheters. Staphylococcus aureus is the predominant causative organism in TVIE. The diagnosis of infective endocarditis (IE) is based on clinical manifestations, blood cultures, and the presence of valvular vegetations detected by echocardiography. Complementary imaging is helpful when there is ongoing clinical suspicion for IE following initially negative echocardiography. Multislice computed tomography allows for assessment of extra-cardiac complications in TVIE, including pulmonary septic emboli. 18F-fluorodeoxyglucose positron emission tomography/computed tomography and radiolabelled white blood cell, single-photon emission computed tomography provide important clinical information concerning the presence of IE in right-sided prosthetic valves or cardiac implantable electronic devices. The aim of this review is to provide an update on TVIE, discussing the role of multimodality imaging in TVIE and the management of these patients.

Right-Side Endocarditis: A Typical Presentation in an Atypical Patient

Right-side endocarditis (RSE) is a well-defined clinical entity, rarer than left-side endocarditis. Known risk factors include intravenous drug use or the presence of medical devices. The most frequently affected valve is the tricuspid valve. In most cases, medical treatment is enough. Surgical treatment is reserved for failed medical therapy or in the presence of large vegetations. Although there is a high recurrence rate in intravenous drug users (IDU), RSE has a generally good prognosis. We present the case of a 70-year-old male with no known previous diseases other than alcohol abuse. He was admitted with fever, cough, hemoptysis and a weight loss of 8 kg in two months. Chest X-ray revealed two images of condensation, one in the right pulmonary base and another in the superior right lobe. A computerized tomography of the thorax revealed a subsegmental pulmonary embolism. The patient refused hospitalization and was discharged medicated with levofloxacin and apixaban. In ambulatory, there was a decrease in size of the lesions but with a new lesion in the right hemithorax. Two months after the first episode, the patient is admitted with the same symptoms. The transthoracic echocardiogram showed a 20cm vegetation in the tricuspid valve. He was admitted to the hospital and received treatment with penicillin and gentamicin after isolation of Streptococcus mitis in the blood cultures. Surgical treatment was needed after a weak response to antibiotics, with a good evolution.

Infective endocarditis with embolic renal infarct presenting as acute abdomen

Infective endocarditis (IE) is a disease that is rare but potentially fatal and challenging to diagnose. A 28-year-old man with sickle cell trait and a history of intravenous drug use presented with abdominal pain and hematuria mimicking a surgical abdomen. The preliminary diagnosis was cholecystitis or perforated viscus. The chest radiograph was indicative of pulmonary septic emboli. Computed tomography was initially thought to show pyelonephritis, but further review of images revealed renal infarct. The patient was found to have endocarditis which resulted in an embolic renal infarct. The patient recovered remarkably well after 60 days of intravenous antibiotics. This case demonstrates that a surgical abdomen may also be a sign of endocarditis, and multiple imaging studies may be required to confirm the diagnosis. In patients such as intravenous drug users with an increased risk of IE, unexplained flank pain should raise a suspicion of acute renal infarction.

Purulent pericarditis-induced intracardiac perforation and infective endocarditis due to Parvimonas micra: a case report

BACKGROUND

Purulent pericarditis, a rare disease with a high associated mortality rate in patients without adequate treatment, can cause serious complications, such as perforation of the surrounding tissue and organs. Parvimonas micra is a very rare cause of purulent pericarditis.

CASE SUMMARY

A 70-year-old male patient presented to our emergency room with chest pain of 10 days' duration. An electrocardiogram showed ST-segment elevation and PR-segment depression on multiple leads. A transthoracic echocardiogram showed normal left ventricular function and a large amount of pericardial effusion. Acute pericarditis was diagnosed, and anti-inflammatory drug therapy was initiated. Due to the lack of improvement in the symptoms, pericardiocentesis was performed on Day 8 and revealed about 800 cc of the bloody fluid. Parvimonas micra was detected in a culture of the pericardial effusion and blood. Although intravenous antibiotic therapy was initiated for purulent pericarditis, his fever persisted. Computed tomography of the chest performed on Day 14 showed an abscess cavity in the pericardial space around the right atrium (RA). Furthermore, transoesophageal echocardiography revealed vegetation in the RA. Emergency surgery confirmed the presence of vegetation and minor perforation of the RA with communication to the abscess cavity. After surgical therapy, the patient clinically improved and was discharged on Day 51.

DISCUSSION

In cases of acute pericarditis, purulent pericarditis should be considered if clinical improvement is not observed after initial treatment with anti-inflammatory drugs. Once the diagnosis of purulent pericarditis is made, aggressive source control is necessary for improved clinical outcomes.

Right-Sided Infective Endocarditis: The Importance of Vegetation Size

BACKGROUND

Right-sided infective endocarditis (IE) carries favourable prognosis compared to left-sided IE. However, the prognostic significance of vegetation size in right-sided IE is less well defined. This study reports the clinical, microbiological, and echocardiographic findings associated with right-sided IE and examines the predictors of adverse outcomes.

METHODS

Consecutive adults admitted with isolated right-sided IE at an Australian tertiary referral centre between June 1999 and May 2017 were retrospectively reviewed. Patients were stratified according to intravenous drug user (IVDU) status. Culprit organisms, sepsis severity, treatment regimens, inpatient complications, and vegetation size were recorded. Hospital survivors were followed mean 6.9±4.8 years for late mortality and IE recurrence.

RESULTS

Of 318 consecutive cases of IE, 60 (19%) were isolated right-sided IE and included in this study. Forty-three (43) (72%) patients were current IVDUs, who were younger and more likely to have hepatitis. The majority (90%) of patients were medically managed with multi-agent antimicrobial regimens (median three agents) for a total duration of median 91 days. In-hospital mortality was 3% (2/60). Septic emboli were found in 82% (49/60) of patients, were significantly more common among IVDUs but were not related to vegetation size. Survival after hospital discharge was 100% at 1 year, 96% at 3 years, and 89% at 5 years. Vegetation size >2 cm, chronic kidney disease, and Pitt bacteraemia score were independent predictors of all-cause late mortality. Freedom from IE recurrence was 93% at 1 year, 87% at 3 years, and 84% at 5 years. Vegetation >2.5 cm, prisoner status, and multivalvular IE involvement conferred higher risks of recurrence.

CONCLUSIONS

Patients with right-sided IE and small vegetations do well with medical management and this should continue to be the preferred strategy. However, those with large vegetations have poorer late outcomes and may require more aggressive treatment and closer follow-up.

A narrative review of echocardiography in infective endocarditis of the right heart

Infective endocarditis (IE) is characterized by bacterial or fungal masses that form in the cardiac chambers and valves, and in severe cases invade the endocardium or intra-cardiac vessels. Right-sided IE accounts for 5% to 10% of cases, with a low mortality cited at 6%. A history of intravenous drug abuse (IVDU) is present in 90% of isolated right-sided IE cases, with normal intra-cardiac anatomy prior to infection in approximately 80%. Nevertheless, up to 50% of patients require early surgical intervention which is associated with significant peri-operative morbidity. Echocardiography is the gold standard for diagnosis with a sensitivity of 80% for the transthoracic modality and 95% for transesophageal studies; it provides important clinical information regarding the severity of infection and development of secondary complications. This includes identification of active infective vegetations, healed IE, prosthetic valve IE, and abscess formation and rupture. Prompt clinical, microbiologic, and imaging assessment of patients with suspected left or right-sided IE is of paramount importance and is reflected in the modified Duke criteria, the well-validated algorithm for accurate and timely diagnosis of IE. Data suggests the criteria sensitivity may be decreased in right-sided IE only, and thus, care must be taken to perform skilled and detailed echocardiographic assessments of the right heart in suspected cases. Herein we provide a review of IE of the right heart, with a focus on pathophysiology and its echocardiographic presentation and characteristics.

Case report: isolated pulmonary valve endocarditis in a 39-year-old patient with intravenous drug abuse

Background 

Isolated pulmonary valve endocarditis is a very rare form of right-sided infective endocarditis. Due to the anatomy, in most cases, just the tricuspid valve is involved. Diagnosis can be challenging because of non-specific symptoms (fever, dyspnoea, haemoptysis, and pleuritic chest pain) and difficulty of detection by echocardiography. Risk factors include intravenous drug abuse, congenital heart disorders, alcohol abuse, male sex and central venous catheters, or pacemaker leads.

Case summary 

A 39-year-old homeless male patient, who was a current intravenous drug user, presented with fever, dyspnoea, and haemoptysis. The chest X-ray showed bilateral infiltrates. Empiric antibiotic treatment was initiated. Blood cultures showed the presence of Streptococcus dysgalactiae. Atypical causes of pneumonia were excluded. Systemic embolism was suspected, and a computed tomography scan of brain, thorax, and abdomen was performed. Multiple septic embolic lesions were detected in both lungs. Echocardiography revealed an isolated pulmonary valve endocarditis. Penicillin G and gentamycin were administered intravenously for a duration of 6 and 2 weeks, respectively. The patient was discharged in stable condition but did not return for outpatient clinical appointments.

Discussion 

To detect rare causes of right-sided infective endocarditis, repeated echocardiograms with special focus on the pulmonary valve may be required. Usually, antibiotic treatment alone leads to recovery. In special situations (heart failure, septic shock, or large vegetation size) surgery is required. Due to the high risk of postoperative complications, surgery in intravenous drug users should be avoided if possible.

Clinical characteristics, microbiology, and outcomes of infective endocarditis in Qatar

Background: Infective endocarditis (IE) is a serious and potentially life-threatening disease. The epidemiology, treatment options, and outcomes have changed considerably over the last two decades. The aim of the study was to describe the epidemiology, clinical characteristics, and outcomes of patients with IE in Qatar.

Methods: Patients were identified from Hamad Medical Corporation hospitals’ electronic records, the national referral center for the State of Qatar. We included those aged ≥ 18 years with Duke Criteria-based diagnosis of IE during the period from January 2015 to September 2017. Demographic and clinical data were retrieved. Descriptive statistics were performed, and logistic regression analysis was used to describe the relationship between patient characteristics and all-cause in-hospital mortality. All potentially relevant variables were included in the univariate analysis, while those with p < 0.1 in the univariate logistic regression model were included in the multivariate analysis. For the final model, we calculated odds ratios (OR) adjusted for each of the variables included, along with their 95% confidence intervals (95% CI). Data were analyzed using STATA software version 15 (StataCorp, College Station, Texas, USA). The study was approved by the Institutional Research Board with a waiver for informed consent.

Results: Fifty-seven cases were included, of which 70% were males. The mean age was 51 years ( ± 16.8 years). Eleven (19%) were associated with prosthetic valves, and 6 (11%) with implantable cardiac devices. Fever (84%), dyspnea (46%), and heart failure (37%) were the most common presentations. Only 58% of patients had known preexisting valvular heart disease or an intracardiac device. Skin infections (10 patients, 18%) were the most prevalent portals of infection, followed by venous catheters, recent valve surgery, and implantable cardiac devices. Staphylococci were implicated in 19 (34%) and Streptococcaceae in 9 (16%) patients, whereas 21 (37%) patients were culture negative. Left-side IE (49 patients, 86%) was predominant. Acute kidney injury (AKI) (17 patients, 30%) and heart failure (11 patients, 19%) were common complications. The majority of patients received targeted antimicrobial therapy with at least two active agents. Only 9 (16%) patients underwent surgical intervention. Fourteen (25%) patients died of any cause before hospital discharge. Logistic regression analysis identified septic shock [OR 57.8, 95% CI 2.6–1360.2; p < 0.01] and AKI OR 33.9, 95% CI 2.9–398.1; p < 0.01) as the only risk factors independently associated with in-hospital mortality.

Conclusion: Staphylococci are the most common microbiological cause of IE in Qatar. Surgical intervention is uncommon, and mortality is relatively high. Our findings suggest that efforts should be directed toward improving IE prevention strategies in high-risk patients, encouraging early microbiological investigations and improving medical and surgical management.

Drug use associated tricuspid valve infective endocarditis in pregnancy

BACKGROUND AND AIM

We report a case of intravenous drug use associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-week gestation.

METHODS

Patient management required a multidisciplinary collaboration between cardiac surgery, obstetrics and gynecology, and neonatal critical care.

RESULTS

Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement 1 week later.

CONCLUSIONS

Both the patient and her infant were successfully managed through the perioperative period.

Systemic septic emboli in tricuspid endocarditis due to an atrial communication with a right-to-left shunt

We present the case of a patient admitted to hospital in septic shock. He had a history of tricuspid valve infective endocarditis (IE) 6 months prior and regularly injected intravenous drugs. A bedside echo on arrival confirmed vegetations on his tricuspid valve, torrential tricuspid regurgitation and signs of significantly raised right-sided pressures. The admission chest radiograph showed consolidative changes in the lungs, suggestive of septic pulmonary emboli. He was commenced on antibiotics and treated in the high-dependency unit. He subsequently developed an acutely ischaemic right foot and nasal tip. Suspicions were raised of a paradoxical septic embolus through a right-to-left shunt, subsequently confirmed on bubble echo which showed passage of agitated saline between the atria. This was not apparent clinically or on echocardiogram during his previous episode of tricuspid valve IE, raising the possibility of the development of an acquired inter-atrial communication since his previous episode.

A changing profile of infective endocarditis at a tertiary hospital in China: a retrospective study from 2001 to 2018

Background

Infective endocarditis (IE) is a lethal disease which has been changing significantly over the past decades; however, information about IE in China remains scarce. This study surveyed the changes in clinical characteristics of IE at a tertiary hospital in south China over a period of nearly 18 years.

Methods

Medical records with IE patients consecutively hospitalized between June 2001 and June 2018 were selected from the electronic medical records system in Nanfang Hospital of Southern Medical University. Data were divided by admission time into two groups equally: early-period group, June 2001 to December 2009 and later-period group, January 2010 to July 2018.

Results

A Total of 313 IE patients were included in our study. Compared with the early-period group, patients in the later-period group included fewer intravenous drug users (IVDUs), older age at onset, reduced development of pulmonary embolism, less renal dysfunction, decreased proportion of Staphylococcus aureus infection and fewer vegetations observed in the right heart by echocardiography. The later-period group also showed a higher proportion of ischemic strokes and higher proportion of positive microbiological findings compared with the early-period group. The in-hospital mortality remained about the same between the two periods and the multivariate analysis identified intravenous drug addicted, prosthetic valve endocarditis, hemorrhagic stroke, acute congestive heart failure, renal insufficiency, left-sided endocarditis, early surgical as independent predictors of in-hospital mortality.

Conclusions

Our study demonstrated a dramatic change in the profile of IE over a period of 18 years at a tertiary hospital in south China and presented several independent predictors of in-hospital mortality. The geographic variations observed in our study will be of important value to profile the clinical feature of China and offer the reference for clinical decisions in our region.

Characteristics and outcomes of patients with right-sided endocarditis undergoing cardiac surgery

Background

There has been an increasing incidence of right-sided infective endocarditis (RSIE) due to the global rise of intravenous drug use (IVDU) and an increasing number of implantable cardiac electronic devices and central venous catheters. Our aim was to investigate differences in the clinical presentation, microbiological findings and prognosis of patients undergoing surgery for RSIE compared to left-sided infective endocarditis (LSIE).

Methods

Relevant clinical data of all 432 consecutive patients undergoing valve surgery for infective endocarditis (IE) at our institution between January 2009 and December 2018 were retrospectively analyzed. Acquired data included patients' demographic and preoperative comorbidities, manifestation of IE according to the recently modified Duke Criteria, perioperative data and relevant clinical outcomes.

Results

A total of 403 patients (93.3%) underwent surgery for LSIE and twenty-nine patients (6.7%) for RSIE. Eleven patients with RSIE (37.9%) showed a concomitant left-sided infection. Compared to LSIE, RSIE patients were significantly younger [47.5 (40.4-69.3) vs. 65.1 (53.7-74.6); P=0.008] and presented with less comorbidities such as hypertension (41.4% vs. 65.3%; P=0.010) and coronary artery disease (6.9% vs. 29.0%; P=0.010). Rates of IVDU (34.5% vs. 4.5%; P<0.001), human immunodeficiency virus (HIV) (10.3% vs. 1.7%; P=0.023) and hepatitis C virus (HCV) infection (24.1% vs. 5.2%; P=0.001) were greater in RSIE. The proportion of Staphylococcus aureus IE was significantly higher in RSIE compared to LSIE (37.9% vs. 21.1%; P=0.035). 30-day mortality was 6.9% after surgery for RSIE compared to 14.6% after operation for LSIE (P=0.372).

Conclusions

Patients undergoing surgery for RSIE compared to LSIE presented with a higher rate of pulmonary septic emboli, more Staphylococcus aureus infections and larger vegetations. Larger multicenter prospective trials are needed to provide more reliable data on the clinical profile of these patients, in order to determine optimal surgical management.

Surgical Treatment of Infective Endocarditis in Pulmonary Position-15 Years Single Centre Experience

Background and Objectives: Infective endocarditis in the pulmonary position is a rare disease. Isolated pulmonary valve endocarditis is extremely rare. The aim of our study was to assess patients who were treated surgically for pulmonary endocarditis at our institution from January 2003 to December 2017. Materials and Methods: We analyze eight cases of infectious endocarditis in pulmonary position out of 293 patients who were operated for infective endocarditis (2.7%, 8/293). Only two of these eight patients were not related to congenital heart malformation. They were followed for early and late mortality, long-term survival, postoperative morbidity and reoperations. Results: Among six patients suffering from congenital heart disease, four patients underwent corrections of pulmonary valve malformation previously, and their infected grafts were replaced by two allografts and two xenografts. The two other patients had replaced their infected pulmonary valves with allografts. Two non-congenital patients with pulmonary valve endocarditis underwent valve replacement with biological prosthesis. All patients survived the early postoperative course. The mean follow-up time was 9.1 (interquartile range (IQR), 5.3-12.6) years. The long-term follow-up included seven patients. One patient (12.5%, 1/8) died more than 4 years after the surgery due to sepsis. Pulmonary endocarditis was the rarest endocarditis treated surgically (p < 0.001). Conclusion: Surgery for infective endocarditis in the pulmonary position (IEPP) is an effective method of treatment with excellent early outcome and good late results despite a very uncommon pathology and few operations being performed. Surgery performed earlier may make the procedure less radical.

Roots of the Resurrection Plant Tripogon loliiformis Survive Desiccation Without the Activation of Autophagy Pathways by Maintaining Energy Reserves

Being sessile, plants must regulate energy balance, potentially via source-sink relations, to compromise growth with survival in stressful conditions. Crops are sensitive, possibly because they allocate their energy resources toward growth and yield rather than stress tolerance. In contrast, resurrection plants tightly regulate sugar metabolism and use a series of physiological adaptations to suppress cell death in their vegetative tissue to regain full metabolic capacity from a desiccated state within 72 h of watering. Previously, we showed that shoots of the resurrection plant Tripogon loliiformis, initiate autophagy upon dehydration as one strategy to reinstate homeostasis and suppress cell death. Here, we describe the relationship between energy status, sugar metabolism, trehalose-mediated activation of autophagy pathways and investigate whether shoots and roots utilize similar desiccation tolerance strategies. We show that despite containing high levels of trehalose, dehydrated Tripogon roots do not display elevated activation of autophagy pathways. Using targeted and non-targeted metabolomics, transmission electron microscopy (TEM) and transcriptomics we show that T. loliiformis engages a strategy similar to the long-term drought responses of sensitive plants and continues to use the roots as a sink even during sustained stress. Dehydrating T. loliiformis roots contained more sucrose and trehalose-6-phosphate compared to shoots at an equivalent water content. The increased resources in the roots provides sufficient energy to cope with stress and thus autophagy is not required. These results were confirmed by the absence of autophagosomes in roots by TEM. Upregulation of sweet genes in both shoots and roots show transcriptional regulation of sucrose translocation from leaves to roots and within roots during dehydration. Differences in the cell's metabolic status caused starkly different cell death responses between shoots and roots. These findings show how shoots and roots utilize different stress response strategies and may provide candidate targets that can be used as tools for the improvement of stress tolerance in crops.

Comparison of Clinical Characteristics and Prognosis in Patients with Right- and Left-sided Infective Endocarditis

OBJECTIVE

Right-sided endocarditis (RSE) accounts for 5%-10% of all cases of infective endocarditis (IE) and frequently has different etiological, pathogenetic, and clinical presentations compared with left-sided endocarditis (LSE). The aims of this study were to evaluate the epidemiologic and clinical characteristics and prognosis of RSE patients and to compare them with those of LSE patients. This study's importance relates to the local understanding of RSE and LSE, since Israeli demographics are different compared to the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence.

MATERIAL AND METHODS

A retrospective cohort study of 215 patients with infective endocarditis was performed. The primary outcome was in-hospital mortality. The secondary outcomes were duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality.

RESULTS

Of the 215 patients in the study, 176 had LSE and 39 had RSE. The RSE patients were younger than the LSE patients (48.1±18.9 years versus 61.8±17.0 years, P<0.001). The most common pathogen in both groups was Staphylococcus aureus, which occurred more in the RSE group (51%) versus the LSE group (19%). In-hospital mortality was lower among patients with RSE (2.6% versus 17%, P<0.037).

CONCLUSIONS

Our study demonstrated an increasing percentage of RSE compared to LSE among patients with IE. Pacemaker lead infection has become the leading cause of RSE in intravenous drug users (IVDU), although less common in Southern Israel. The etiological and clinical differences between RSE and LSE are noteworthy. Patients with RSE have a better prognosis than those with LSE.

Trends in pulmonary embolism in patients infected with HIV during the combination antiretroviral therapy era in Spain: A nationwide population-based study

Chronic infections are a major factor in the development of pulmonary embolism (PE). We aimed to evaluate the trends of PE-related hospitalizations and PE-related deaths in people living with HIV (PLWH) during the era of combination antiretroviral therapy (cART) through a retrospective study in Spain. Data were collected from the Minimum Basic Data Set (MBDS) between 1997 and 2013. The study period was fragmented into four calendar periods (1997–1999, 2000–2003, 2004–2007, and 2008–2013). The rate of PE-related hospitalizations remained stable in PLWH (P = 0.361). HIV-monoinfected patients had a higher incidence than HIV/HCV-coinfected patients during all follow-up [(98.7 (95%CI = 92.2; 105.1); P < 0.001], but PE incidence decreased in HIV-monoinfected patients (P < 0.001) and increased in HIV/HCV-coinfected patients (P < 0.001). Concretely, the rate of PE-related hospitalizations decreased significantly in patients monoinfected with HIV [from 203.6 (95%CI = 175.7; 231.6) events per 100,000 patient-years in 1997–1999 to 74.3 (95%CI = 66.1; 82.3) in 2008–2013; P < 0.001], while patients coinfected with HIV/HCV had a significant increase [from 16.3 (95%CI = 11; 21.6) in 1997–1999 to 53.3 (95%CI = 45.9; 60.6) in 2008–2013; P < 0.001]. The mortality rate of PE-related hospitalizations showed a similar trend as PE incidence. In conclusion, the epidemiological trends of PE in PLWH changed during the cART era, with decreases in incidence and mortality in HIV-monoinfected and increases in both variables in patients coinfected with HIV/HCV.

18F-FDG-PET/CT Imaging to Diagnose Septic Emboli and Mycotic Aneurysms in Patients with Endocarditis and Cardiac Device Infections

PURPOSE OF REVIEW

This review analyzes recent studies evaluating the diagnostic value of ¹⁸F-FDG-PET/CT for the detection of peripheral emboli and secondary infectious foci in patients with infective endocarditis and cardiac device infections.

RECENT FINDINGS

Detection of extracardiac septic localizations in patients with infective endocarditis and cardiac device infections is crucial, as it may impact the diagnosis, prognosis, and therapeutic management. Recent literature substantiated the clinical usefulness of ¹⁸F-FDG-PET/CT in this setting. ¹⁸F-FDG-PET/CT has proven its high diagnostic value for the detection of peripheral emboli in patients with infective endocarditis and cardiac device infections, substantially affecting patients' outcome and treatment. A multimodal approach, combining the high sensitivity of ¹⁸F-FDG-PET/CT with morphological imaging seems promising.