Two cases of Francisella tularensis subspecies holartica prosthetic valve endocarditis, and review of the literature.

Francisella tularensis endocarditis is rare and difficult to diagnose, and only a few cases have been described. We report two new cases of endocarditis due to F. tularensis subsp. holarctica, with a favorable evolution after appropriate antibiotic therapy and valve replacement surgery, and review the 5 other cases reported in the literature. This rare infection may be suspected based on the local epidemiology and the patient's exposure factors. A regimen of ciprofloxacin and gentamicin, combined with surgical valve replacement if necessary, appears to be effective in treating F. tularensis endocarditis.

Prosthetic Valve Endocarditis Caused by Pasteurella dagmatis, Germany.

An 81-year-old male patient in Germany had prosthetic valve endocarditis caused by Pasteurella dagmatis after a domestic cat bite. We surgically treated a paravalvular abscess and administered definitive antibiotic therapy consisting of penicillin G and levofloxacin. The patient was discharged from the intensive care unit in good condition 21 days after the surgery.

Antibiotic Prophylaxis for Genitourinary Procedures in Patients with Artificial Joint Replacement and Artificial Heart Valves.

Prosthetic joint infection (PJI) and prosthetic valve endocarditis (PVE) are uncommon but serious complications. According to current best practice statements, prior to a genitourinary procedure, patients with prosthetic joints should receive antibiotic prophylaxis if they are within 2 years of arthroplasty, if they are high risk for infection due to their individual comorbidities, or if the procedure poses a high risk for bacteremia. Patients with prosthetic valves should not receive antibiotic prophylaxis for the sole purpose of prevention of endocarditis. Enterococcus species are the uropathogens most often associated with PJI and PVE. Antibiotic selection should take into account local resistance patterns.

Surgery Versus Thrombolytic Therapy for the Management of Left-Sided Prosthetic Valve Thrombosis Without Hemodynamic Compromise: A Systematic Review and Meta-Analysis.

BACKGROUND: The optimal strategy in prosthetic heart valve thrombosis (PVT) remains controversial, with no randomized trials and conflicting observational data. We performed a systematic review and meta-analysis of evidence comparing systemic thrombolysis and cardiac surgery in PVT. METHODS AND RESULTS: We searched PubMed, the Cochrane Library, and Embase for studies on treatment strategies in patients with left-sided PVT since 2000. The primary outcome was death, and the secondary outcomes were major bleeding and thromboembolism during follow-up (International Prospective Register of Systematic Reviews No. CRD42022384092). We identified 2298 studies, of which 16 were included, comprising 1389 patients with PVT (mean age, 50.4±9.3 years; 60.0% women). Among them, 67.2% were New York Heart Association stage III/IV at admission. Overall, 48.1% were treated with systemic thrombolysis and 51.9% with cardiac surgery. The mortality rate was 10.8% in the thrombolysis group and 15.3% in the surgery group. The pooled risk difference for death with systemic thrombolysis was 1.13 (exact CI, 0.74-1.79; ζ2=0.89; P<0.001) versus cardiac surgery. Rates of both transient ischemic attack and non-central nervous system embolism were higher in the thrombolysis group (P=0.002 and P=0.02, respectively). Treatment success, major bleeding, and stroke were similar between groups. Sensitivity analysis including studies that used low-dose or slow-infusion thrombolysis showed that the mortality rate was lower, and treatment success was higher, in patients referred to systemic thrombolysis, with similar rates of other secondary outcomes. CONCLUSIONS: There is evidence to suggest that thrombolysis might be the preferred option for the management of PVT without cardiogenic shock, pending future randomized controlled trials or larger observational studies.

Detection of infective endocarditis with [64Cu]Cu-DOTATATE positron emission tomography/computed tomography: a case series.

Background: Infective endocarditis (IE) is a serious and fatal condition, with prosthetic valve endocarditis representing the worst prognosis. The recommended nuclear imaging modality 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography ([18F]FDG PET/CT) has limitations. In this case series, we present two patients with IE scanned with a novel PET tracer [64Cu]Cu-DOTATATE ([64Cu]Cu-[1,4,7,10-tetraazacyclododecane-N,N',N″,N‴-tetra acetic acid]-d-Phe1, Tyr3-octreotate). Case summary: An 84-year-old female patient (Patient 1) with a biological mitral valve prosthesis (MVP) was admitted acutely from the outpatient clinic. Transoesophageal echocardiography showed vegetations on the MVP. The patient underwent [64Cu]Cu-DOTATATE PET/CT, which showed uptake at the site of infection. The patient underwent surgical valve replacement. The post-operative period was without significant complications, and the patient was discharged home. In another case, a 72-year-old male patient (Patient 2) with a medical history of mild mitral valve stenosis, aortic valve stenosis, and gastrointestinal stromal tumour was admitted to the hospital for back and abdominal pain and subfebrile episodes. Transoesophageal echocardiography showed large vegetations in the native aortic valve. The patient underwent [64Cu]Cu-DOTATATE PET/CT, which showed no uptake at the site of the suspected infection. The patient underwent surgical valve replacement. The post-operative period was characterized by Candida albicans sternitis, and after prolonged hospitalization, the patient died of respiratory failure as a complication of sepsis. Discussion: In conclusion, this is the first case series presenting two patients with definite IE (modified Duke criteria), who were scanned with the novel [64Cu]Cu-DOTATATE PET/CT. Patient 1, with endocarditis in the MVP, showed an uptake of the tracer, while Patient 2, with native aortic valve endocarditis, did not show any uptake.

Ultraslow low-dose thrombolytic therapy in patients with acute mechanical prosthetic heart valve thrombosis - A prospective cohort study.

BACKGROUND: While surgery still remains the gold standard treatment for mechanical prosthetic valve thrombosis (MPVT) by many guidelines, the ultraslow low-dose thrombolytic regimen has been reported as a promising alternative. METHODS: In this prospective single-center cohort, patients with acute MPVT were treated with an ultraslow low-dose thrombolytic regimen consisting of 25 mg infusion of recombinant tissue-type plasminogen activator (rtPA) over 25 h. The regimen could be repeated in case of failure until resolution/occurrence of adverse events or a maximum cumulative dose of 150 mg. The primary outcome was the complete MPVT resolution rate; other outcomes included first-dose success rate, major bleeding, thromboembolic events, mortality, and total thrombolytic dose/duration. RESULTS: Between April 2018 to January 2024, 135 episodes of acute MPVT were treated with an ultraslow low-dose thrombolytic regimen in 118 patients. In 118/135 (87.4 %) episodes, right-sided prosthetic valve was involved. Complete success was achieved in 88.1 % of cases, with 39.5 % responding after the first dose. The median total dose was 50 mg over a median of 30 h. Only one fatal intracranial hemorrhage occurred (0.7 %), with no other bleeding or thromboembolic complications. CONCLUSION: The ultraslow low-dose thrombolytic regimen appears to exhibit high efficacy and acceptable safety in treating acute MPVT. Further large clinical trials are essential for validating these preliminary findings.

Infective Endocarditis in Patients With Bicuspid Aortic Valves: Unique Clinical and Microbiologic Features.

OBJECTIVE: Patients with bicuspid aortic valves (BAV) are at increased risk of infective endocarditis (IE). Information of the clinical presentation and the microbiology of BAV-associated IE, however, is limited. Therefore, our study aimed to characterise the clinical features native valve endocarditis (NVE) in the setting of BAV and compared them to patients with prosthetic valve endocarditis (PVE) following BAV replacement. METHODS: Adult patients with BAV or history of BAV with aortic valve replacement (AVR) and a definite or possible IE diagnosis within the Mayo Clinic Enterprise (USA) from January 2008 to December 2021, were included. BAV was confirmed by trans-oesophageal echocardiography. IE was defined according to the modified Duke criteria and only an initial episode was included. Statistical analyses were performed to compare clinical characteristics, microbiology, and IE complications. RESULTS: Overall, 161 patients with BAV and IE (NVE [n=60], 37.3%) and PVE [n=101, 62.7%) were included. Mean age±SD was 56.5±16.1 years, and 139 (86.3%) patients were males. PVE patients were older (p<0.01) and had a higher rate of hypertension (p<0.01), chronic heart failure (p<0.01), chronic kidney disease (p<0.01), and perivalvular abscess (p<0.01). BAV patients with NVE had a higher prevalence of isolated mitral valve IE (p<0.01), moderate to severe aortic valve regurgitation (p<0.01) and combined aortic with mitral valve IE (p<0.01). Streptococcus mitis was the most common pathogen in NVE (30.0%) while Staphylococcus aureus was the most common in PVE (15.8%). CONCLUSIONS: Patients with BAV are at risk of both NVE and PVE. Each syndrome has unique clinical features, including microbiologic findings, that should be appreciated in IE diagnosis and management.

Homograft Aortic Root Replacement for Destructive Prosthetic Valve Endocarditis: Results in the Current Era.

Background: Destructive aortic prosthetic valve endocarditis portends a high morbidity and mortality, and requires complex high-risk surgery. Homograft root replacement is the most radical and biocompatible operation and, thus, the preferred option. Methods: A retrospective analysis was conducted on 61 consecutive patients who underwent a cardiac reoperation comprising homograft aortic root replacement since 2010. The probabilities of survival were calculated with the Kaplan-Meier method, whereas multivariable regression served to outline the predictors of adverse events. The endpoints were operative/late death, perioperative low cardiac output and renal failure, and reoperations. Results: The operative (cumulative hospital and 30-day) mortality was 13%. The baseline aspartate transaminase (AST) and associated mitral procedures were predictive of operative death (p = 0.048, OR [95% CIs] = 1.03 [1-1.06]) and perioperative low cardiac output, respectively (p = 0.04, OR [95% CIs] = 21.3 [2.7-168.9] for valve replacement). The latter occurred in 12 (20%) patients, despite a normal ejection fraction. Survival estimates (±SE) at 3 months, 6 months, 1 year, and 3 years after surgery were 86.3 ± 4.7%, 82.0 ± 4.9%, 75.2 ± 5.6, and 70.0 ± 6.3%, respectively. Survival was significantly lower in the case of AST ≥ 40 IU/L (p = 0.04) and aortic cross-clamp time ≥ 180 min (p = 0.01), but not when excluding operative survivors. Five patients required early (two out of the five, within 3 months) or late (three out of the five) reoperation. Conclusions: Homograft aortic root replacement for destructive prosthetic valve endocarditis can currently be performed with a near 90% operative survival and reasonable 3-year mortality and reoperation rate. AST might serve to additionally stratify the operative risk.

Atypical Presentation of Coxiella burnetii Endocarditis: Diagnostic Considerations and the Importance of Keeping a Broad Differential.

Coxiella burnetii is a gram-negative bacterium associated with serious complications such as infective endocarditis. Early diagnosis and treatment can be difficult due to its nonspecific presentation and risk factors that include contact with farm animals or their byproducts. Here, we present an atypical presentation of infective endocarditis caused by Coxiella burnetii, where the patient had no risk factors, negative Duke criteria, and negative preliminary workup.

Pushing the hybrid approach to the edges, three stories in one: a case report.

Background: Mitral annular calcification (MAC) is common in the elderly. Extensive calcification has been historically challenging for the cardiac surgeons, with traditional surgical approaches carrying significant risks. Less invasive approaches have recently been explored in an attempt to reduce this risk. Case summary: We report the case of a 75-year-old woman who presented with recurrent pulmonary oedema, due to severe MAC and mitral regurgitation. Her past medical history included bioprosthetic aortic valve replacement 5 years ago. Given the extensive MAC and the patient's frailty, a minimally invasive hybrid approach with direct implantation of a transcatheter balloon expandable Sapien 3 valve was selected to manage her. Although the post-surgical result was initially excellent with elimination of the mitral regurgitation, the patient's post-operative course was marked by two serious complications, namely, acute severe aortic regurgitation, due to rupture of the bioprosthetic valve's right cusp, and severe paravalvular leak of the Sapien valve, due to posterior migration towards the left atrium. These were managed successfully with emergency valve-in-valve implantation using the 'double chimney' technique for the bioprosthetic aortic valve, as well as transeptal valve-in-valve implantation of a 2nd Sapien valve in the mitral valve, which sealed the gap between the 1st Sapien and the calcified mitral annulus. Discussion: This case illustrates a less invasive approach for the management of severe MAC. Complications can still occur in this high-risk group of patients, and therefore, such cases should be managed with close collaboration between cardiac surgeons and cardiologists, in centres with high expertise.

ST-elevation myocardial infarction from septic embolism secondary to prosthetic aortic valve endocarditis: a case report.

Background: ST-elevation myocardial infarction (STEMI) is a cardiac emergency that requires prompt diagnosis and treatment. We describe a challenging and complex case of managing acute STEMI in a patient with severe anaemia, deranged clotting profile, and infective prodrome. Case summary: A 54-year-old Caucasian gentleman was referred by his general practitioner as an emergency after presenting with acute onset of chest pain. His electrocardiogram revealed anterior ST elevation. His past medical history includes a mechanical aortic valve, requiring anticoagulation, and a recent gastrointestinal bleed secondary to type C gastritis. His initial presentation was further complicated by severe anaemia, deranged clotting profile, and elevated infective markers. He required a prompt transfer to the catheterization laboratory to assess and stabilize the situation. We discuss the emerging challenges during treatment, particularly as the diagnosis of septic embolism from infective prosthetic valve endocarditis was unfolding, requiring urgent cardiac surgery. Discussion: Acute coronary vessel closure leading to STEMI from septic embolism secondary to prosthetic aortic valve endocarditis is very rare. It is essential to consider the whole picture of the presentation for timely diagnosis and tailored treatment.

Infective Endocarditis Caused by Carbapenemase-Producing Klebsiella pneumoniae on a Prosthetic Valve: A Case Report and Review of the Literature.

Infective endocarditis (IE) is a rare but severe disease due to frequent and serious complications. Healthcare-associated cases often involve Staphylococcus aureus, while Gram-negative bacteria such as Klebsiella pneumoniae, though rare, pose severe challenges due to their resistance profiles. We report a case of a 68-year-old woman with a history of hypertension and mitral valve replacement 12 years ago, who was admitted to the intensive care unit (ICU) for management of non-traumatic, afebrile altered mental status due to intracerebral hemorrhage from anticoagulant overdose. His stay in the ICU revealed septic shock with multi-organ failure caused by carbapenemase (New Delhi metallo-ß-lactamase (NDM))-producing K. pneumoniae complicated by IE on the prosthetic mitral valve. Despite treatment with meropenem, colistin, and tigecycline, the patient succumbed to septic shock after 15 days of therapy. This case highlights the importance of close surveillance of nosocomial infections and the need for prompt management strategies integrating medical and surgical approaches to reduce the high mortality associated with such infections.

Incidence and outcomes of prosthetic valve thrombosis during peripheral extracorporeal membrane oxygenation.

OBJECTIVES: In the context of postcardiotomy cardiogenic shock (PCCS) following valve replacement surgery, it may be necessary to implant a peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO). This procedure, however, carries a risk of prosthetic valve thrombosis. The aim of this retrospective study was to describe the incidence and outcomes of prosthetic valve thrombosis after VA-ECMO support for PCCS and to report the associated risk factors. METHODS: All consecutive adult patients who received pVA-ECMO for PCCS following a valve replacement procedure between January 2015 and October 2019 in our institution were included in this retrospective study. Outcome variables were prosthetic valve thrombosis, 30-day and hospital survival, pVA-ECMO-associated adverse events and surgery-related adverse events. RESULTS: During the 4-year study period, 549 patients received pVA-ECMO for PCCS. Among them, 152 had undergone a valve replacement procedure and 9 of these developed prosthetic valve thrombosis. The incidence of valve thrombosis at 30 days was 7.5 ± 2%. The cumulative Incidence of prosthetic valve thrombosis was significantly lower with pVA-ECMO + IABP versus VA-ECMO alone (1.4 ± 1.4% vs 13.7 ± 4.7%, p = 0.021, respectively). Intra-aortic balloon pump use associated with pVA-ECMO (versus pVA-ECMO alone) was an independent protective factor against hospital death (OR = 0.180 [0.068-0.478], p = 0.001). CONCLUSIONS: After PCCS following valve replacement surgery, peripheral femoro-femoral VA-ECMO is associated with a low risk of acute valve thrombosis especially when associated with an IABP.

Percutaneous versus surgical closure of paravalvular leaks in prosthetic valves: A cross-sectional comparison of clinical outcomes.

Background and Aims: Paravalvular leak (PVL) is a serious complication of prosthetic valve replacement. Both surgical and percutaneous closure techniques are used for PVL closure, but optimal strategies and comparative outcomes are uncertain. This study aimed to compare the efficacy and safety of percutaneous versus surgical PVL closure by analyzing changes in leak severity, functional status, echocardiographic parameters, and clinical outcomes. Methods: A total of 72 patients were included in this retrospective cross-sectional single-center study comparing percutaneous (n = 25) and surgical (n = 47) PVL closure from 2015 to 2022. Demographics, medical history, echocardiograms, laboratory data, complications, and mortality data were extracted from the records. Changes in leak severity, NYHA class, echocardiographic parameters, and clinical outcomes were compared between the percutaneous and surgical groups. Results: Both percutaneous and surgical PVL closure significantly reduced leak severity and improved NYHA class (both p < 0.01), with no difference between the quantity of changes in each group. The 30-day mortality was 4% after percutaneous and 6.4% after surgical closure (p = 0.65). At 90 days, mortality was 24% percutaneous versus 17% surgical (p = 0.48). The length of stay in the hospital and post-procedural decrease in hemoglobin were considerably lower in the percutaneous group. The rate of complication rates was similar between the groups. Echocardiographic changes were also comparable. Conclusion: Percutaneous and surgical PVL closure had similar efficacy in reducing leaks and improving symptoms, with no significant difference in early outcomes. Both options should be considered viable for PVL repair after heart team evaluation.

The Commando procedure for mechanical double valve prosthesis endocarditis with destruction of the aortomitral continuity.

Infective endocarditis, particularly after implanting valve prostheses, poses significant surgical challenges, often requiring complex interventions. We describe a case of a 37-year-old male with Staphylococcus aureus endocarditis, unsuccessfully treated with mechanical valve prostheses. Continued infection led to the destruction of the intervalvular fibrous body, necessitating a Commando procedure involving radical debridement and replacement of both aortic and mitral valves with complex patch reconstruction. Prosthesis selection remains contentious, considering recurrence risk and long-term prognosis. Our case underscores timely intervention and meticulous technique in managing such complex situations. It highlights successful strategies for treating infective endocarditis with destruction of aortomitral continuity, emphasizing the pivotal role of the Commando procedure.

Clinical Characterization of Pathogens, Risk Factors and Quality of Life in an Observational Study of Native vs. Prosthetic Aortic Valve Endocarditis Surgery.

Background: Native (NVE) and prosthetic (PVE) aortic valve endocarditis (AVE) remain a surgical challenge with an ongoing trend towards more complex surgical procedures. Methods: First-time NVE was compared with PVE, focusing on pathogens, risk factors, perioperative course, postoperative follow-up, including recurrent infection, as well as health-related quality of life (HRQOL). Results: From 2007 to 2022, surgical intervention for AVE was necessary in 231 patients with 233 episodes of infective aortic valve endocarditis, i.e., there were only two cases of reinfection (NVE group). The study group consisted of 130 cases with NVE and 103 with PVE. Overall, a median of 40.3% of survivors were in NYHA class I or II. In-hospital mortality was higher in the PVE group with 13.3%. The most common pathogen was Staphylococcus aureus, with 24.9% across both groups. EuroSCORE II was higher in the PVE group (19.0 ± 14.3% total, NVE 11.1 ± 8.1%, PVE 27.8 ± 14.6%; p < 0.05), reflecting an older, more co-morbid patient cohort. Abscess formation was also more common in the PVE group, while vegetations were more common in the NVE group. The 5-year and 10-year survival rates did not differ significantly between NVE and PVE and were 74.4% and 52.2% for the NVE group, respectively, and 67.4% and 52.9% for the PVE group, respectively. The HRQOL as assessed by the Minnesota Living with HF Questionnaire (MLHFQ) demonstrated no significant difference between both groups. Conclusions: Long-term survival and QoL after surgical treatment of infective aortic valve endocarditis are excellent and do not depend on the type of replacement.

Emerging and Re-Emerging Pathogens in Valvular Infective Endocarditis: A Review.

Infective endocarditis (IE) is a microbial infection of the endocardial surface, most commonly affecting native and prosthetic valves of the heart. The epidemiology and etiology of the disease have evolved significantly over the last decades. With a growing elderly population, the incidence of degenerative valvopathies and the use of prosthetic heart valves have increased, becoming the most important predisposing risk factors. This change in the epidemiology has caused a shift in the underlying microbiology of the disease, with Staphylococci overtaking Streptococci as the main causative pathogens. Other rarer microbes, including Streptococcus agalactiae, Pseudomonas aeruginosa, Coxiella burnetti and Brucella, have also emerged or re-emerged. Valvular IE caused by these pathogens, especially Staphylococcus aureus, is often associated with a severe clinical course, leading to high rates of morbidity and mortality. Therefore, prompt diagnosis and management are crucial. Due to the high virulence of these pathogens and an increased incidence of antimicrobial resistances, surgical valve repair or replacement is often necessary. As the epidemiology and etiology of valvular IE continue to evolve, the diagnostic methods and therapies need to be progressively advanced to ensure satisfactory clinical outcomes.

Infective Endocarditis Caused by Streptococcus Sinensis in a Patient with Bioprosthetic Aortic Valve: A Case Report and Literature Review.

Background: Infective endocarditis caused by Streptococcus sinensis is exceedingly rare, with only limited cases reported. Here, we present the first documented case of prosthetic valve endocarditis attributed to Streptococcus sinensis. Case Presentation: A 40-year-old Chinese female was admitted with a 45-day history of intermittent fever. The presumed diagnosis was a pulmonary infection and antibiotic therapies failed to alleviate her symptoms. On admission, infective endocarditis was suspected, considering the history of aortic valve replacement and recent dental procedure without prophylactic antibiotics. Transesophageal echocardiography disclosed a 3-millimeter vegetation in the prosthetic aortic valve, and metagenomic next-generation sequencing and mass spectrometry identified Streptococcus sinensis. The patient was diagnosed with infective endocarditis. Antibiotic treatments resulted in temporary clinical improvements, although fluctuations in temperature and inflammatory markers led to multiple attempts at antibiotic therapies. At last, the patient underwent an elective aortic valve replacement with a favorable prognosis. Conclusion: In this case, we demonstrated prosthetic valve endocarditis caused by Streptococcus sinensis, which is an extremely rare pathogen. All reported endocarditis cases caused by Streptococcus sinensis were reviewed and summarized. Most of these patients had rheumatic heart diseases or congenital heart diseases. Antibiotic prophylaxis is important for high-risk procedures. Timely identification of the bacterium is crucial for diagnosis and treatment. Overall, infective endocarditis caused by this bacterium had a good prognosis.

Prosthetic valve infective endocarditis caused by Cutibacterium modestum: a case report.

Background: While Cutibacterium acnes is well known for its potential to cause acne vulgaris, postsurgical infections, and other human infections, few reports have described Cutibacterium modestum infections. Thus, the clinical characteristics of C. modestum as an infectious disease are not well understood. Herein, we describe the characteristics of a case of prosthetic valve infective endocarditis caused by C. modestum. Case summary: An 81-year-old man was admitted to our hospital with fever, general fatigue, and appetite loss. His past medical history included aortic valve replacement surgery and coronary artery bypass grafting for aortic valve stenosis and angina pectoris. Physical examination on admission revealed a body temperature of 39.0°C, blood pressure of 97/68 mmHg, and pulse rate of 101 b.p.m. Transthoracic echocardiography showed no prosthetic valve destruction or malfunction or obvious vegetation adhesion to the prosthetic or other valves. Bacteria initially identified as C. acnes were detected in two sets of anaerobic blood culture bottles collected upon admission. However, as the samples required 111 and 118 h to become blood culture-positive, the possibility of contaminating bacteria was high. Transoesophageal echocardiography revealed vegetation in the artificial valve. Repeated blood culture revealed the same bacteria; thus, contamination was ruled out, and the diagnosis of infective endocarditis was confirmed. Finally, 16S ribosomal RNA gene sequencing identified the detected bacteria as C. modestum rather than C. acnes. Discussion: Including this case, only two cases of prosthetic valve infective endocarditis caused by C. modestum have been reported, the characteristics of which are still poorly understood.